Skip to main content
  • More from ADA
    • Diabetes
    • Diabetes Care
    • Clinical Diabetes
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, abridged
    • ADA Scientific Sessions Abstracts
    • BMJ Open Diabetes Research & Care
  • Subscribe
  • Log in
  • My Cart
  • Follow ada on Twitter
  • RSS
  • Visit ada on Facebook
Diabetes Spectrum

Advanced Search

Main menu

  • Home
  • Current
    • Current Issue
    • Online Ahead of Print
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
  • Browse
    • Issue Archive
    • Saved Searches
    • COVID-19 Article Collection
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
  • Info
    • About the Journal
    • About the Editors
    • ADA Journal Policies
    • Instructions for Authors
    • Guidance for Reviewers
  • Reprints/Reuse
  • Advertising
  • Subscriptions
    • Individual Subscriptions
    • Institutional Subscriptions and Site Licenses
    • Access Institutional Usage Reports
    • Purchase Single Issues
  • Alerts
    • E­mail Alerts
    • RSS Feeds
  • Podcasts
    • Diabetes Core Update
    • Special Podcast Series: Therapeutic Inertia
    • Special Podcast Series: Influenza Podcasts
    • Special Podcast Series: SGLT2 Inhibitors
    • Special Podcast Series: COVID-19
  • Submit
    • Submit a Manuscript
    • Journal Policies
    • Instructions for Authors
  • More from ADA
    • Diabetes
    • Diabetes Care
    • Clinical Diabetes
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, abridged
    • ADA Scientific Sessions Abstracts
    • BMJ Open Diabetes Research & Care

User menu

  • Subscribe
  • Log in
  • My Cart

Search

  • Advanced search
Diabetes Spectrum
  • Home
  • Current
    • Current Issue
    • Online Ahead of Print
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
  • Browse
    • Issue Archive
    • Saved Searches
    • COVID-19 Article Collection
    • ADA Standards of Medical Care
    • ADA Standards of Medical Care, Abridged
  • Info
    • About the Journal
    • About the Editors
    • ADA Journal Policies
    • Instructions for Authors
    • Guidance for Reviewers
  • Reprints/Reuse
  • Advertising
  • Subscriptions
    • Individual Subscriptions
    • Institutional Subscriptions and Site Licenses
    • Access Institutional Usage Reports
    • Purchase Single Issues
  • Alerts
    • E­mail Alerts
    • RSS Feeds
  • Podcasts
    • Diabetes Core Update
    • Special Podcast Series: Therapeutic Inertia
    • Special Podcast Series: Influenza Podcasts
    • Special Podcast Series: SGLT2 Inhibitors
    • Special Podcast Series: COVID-19
  • Submit
    • Submit a Manuscript
    • Journal Policies
    • Instructions for Authors
Departments

Insulin Pump Class: Back to the Basics of Pump Therapy

  1. Sara Wilson Reece, PharmD, CDE, BC-ADM, CPhT and
  2. Cheryl Lynn Hamby Williams, RN, CDE
Diabetes Spectrum 2014 May; 27(2): 135-140. https://doi.org/10.2337/diaspect.27.2.135
PreviousNext
  • Article
  • Figures & Tables
  • Info & Metrics
  • PDF
Loading

In the early 1960s, Dr. Arnold Kadish developed the first insulin pump, which was the size of a Marine backpack.1 Over the years, insulin pumps have become much more refined and have decreased in bulk to the size and weight of a small pager. Insulin pump therapy, also known as continuous subcutaneous insulin infusion, is no longer seen as experimental and controversial, but rather is viewed as an acceptable alternative to multiple daily injection (MDI) therapy in the management of insulin-dependent diabetes2 (Table 1).3

The insulin pump is an electromechanical device that mimics the body's natural insulin secretion from pancreatic β-cells by subcutaneously delivering rapid-acting insulin both at preset continuous basal rates and in extra bolus doses at mealtimes on demand.4 Insulin pumps allow for up to 24 different hourly basal rates in a 24-hour period. For bolus doses, pump users input their current blood glucose level and the number of carbohydrates they will consume, and the pump customizes their dose based on insulin currently on board (i.e., the remaining active insulin from the previous dose), their individualized insulin-to-carbohydrate ratio, and their individualized insulin sensitivity factor (i.e., their expected drop in blood glucose from 1 unit of insulin).1,5 Thus, insulin pumps are able to deliver insulin in a more physiological manner than other injection-based insulin regimens.5

In the late 1970s, results of the first human trials of insulin pump therapy were published. This was followed by numerous additional studies comparing insulin pump therapy to traditional MDI regimens with regard to long-term glycemic control and minimization of hypoglycemia.6–11 Then, in 1993, the Diabetes Control and Complications Trial12 confirmed the importance of intensive glycemic control using either insulin pump therapy or an MDI regimen along with frequent self-monitoring of blood glucose (SMBG).

In patients with type 1 diabetes, pump therapy has been shown to limit excess weight gain, reduce the frequency of severe hypoglycemia, and lower A1C levels.13 Pump therapy is also a therapeutic alternative for insulin-requiring patients with type 2 diabetes, especially those who require large amounts of insulin, have severe insulin resistance, and have poor glycemic control,14,15 and has been observed to reduce insulin requirements and lower A1C levels in patients with type 2 diabetes.14,16 Compared to MDI, insulin pump therapy allows for greater flexibility with timing of meals, reduces the risk of exercise-induced hypoglycemia, allows for overnight glycemic control, and gives patients greater ability to manage their own diabetes.13

Insulin pumps consist of a reservoir, a pump, and an infusion set. The reservoir, which is similar to a syringe, holds a 2- to 3-day supply of insulin and is placed into the battery-powered pump. The infusion set consists of tubing that connects the reservoir to a cannula (i.e., a tiny tube to deliver insulin subcutaneously) and transports the insulin from pump to patient. A small piece of adhesive holds the cannula in place at the insertion site.1 The needle of the infusion set can be inserted into the abdomen, upper thigh, or upper arm. The infusion set and reservoir must be changed every 2–3 days.

View this table:
  • View inline
  • View popup
  • Download powerpoint
Table 1.

Comparison of Current Insulin Pumps3

The indications for insulin pump therapy include inadequate glycemic control (defined as an A1C > 7%, the dawn phenomenon [early-morning increase in blood glucose], and marked variability in glucose from day to day); hypoglycemic episodes requiring assistance or hypoglycemia unawareness; the need for flexibility in lifestyle; and pregnancy or intention to become pregnant.13,17 All candidates should have the willingness and ability to learn how to use an insulin pump and to perform SMBG multiple times per day.1,4

Patients with significant psychological problems such as psychosis or severe depression are not appropriate candidates.4 Ongoing education, motivation, and psychological support are required for patients to succeed with insulin pump therapy. Patient education should include the principles of basal-bolus insulin therapy, sick-day management, carbohydrate counting, glucagon administration, site preparation and infection prevention, prevention and treatment of hypo- and hyperglycemia, and insulin adjustments for exercise.17 The most crucial factors for patient success are patients' willingness to perform frequent SMBG and sufficient ongoing clinical support.17

Program Background

The Longstreet Clinic (TLC) is a regional multidisciplinary physician practice. The Internal Medicine (IM) and Family Medicine (FM) departments are located in Gainesville and Oakwood (Hall County), Ga. Hall County is located in north-east Georgia 50 miles northeast of Atlanta. The population of Hall County is ~ 187,700.

Within the IM and FM departments, the Diabetes Education and Medical Nutritional Therapy department provides diabetes education and management services for patients with diabetes. Within this department, there is an interdisciplinary team of certified diabetes educators (CDEs) composed of a registered nurse (team leader), a registered dietitian, and a pharmacist, all of whom are certified insulin pump trainers. The department offers various services, including individual and group diabetes education, gestational diabetes education and management, pediatric obesity education classes, and insulin pump therapy education and management.

Approximately 20% of all IM and FM patients have diabetes. Forty-seven percent of these diabetes patients are on insulin therapy, of which 3% use an insulin pump. For patients on insulin pump therapy, 99% use the MiniMed Paradigm Revel insulin pump and 1% use other brands of insulin pumps. All insulin pump patients are referred to the diabetes education department for pre-pump, pump start, and follow-up training sessions. After the initial training sessions, many of the insulin pump patients continue to be seen by the diabetes education staff for review of insulin pump downloads and adjustment of pump settings.

The lead CDE conceived the insulin pump class after several patients on pump therapy had severe hypoglycemic episodes while driving. She identified the need for insulin pump patients to have follow-up training to review insulin pump survival skills and prevent future hypoglycemic emergencies. A database search of IM and FM patients was completed to identify the subset of patients on insulin pump therapy.

Via phone or during office visits, CDEs invited established insulin pump patients identified through the database search to attend the class. All insulin pump patients were invited to the subsequent insulin pump classes. Baseline characteristics of the patients who attended the class are described in Table 2.

To assist with class attendance, patients received a reminder call 1 day before class.

Although initial education for insulin pump therapy focuses on the basics of pump operation, the class provides more in-depth education about sick-day management, infusion site problems, and additional keys to pump success. The objectives of the class are to review insulin pump survival skills for new and experienced pump patients to prevent emergency room visits, improve glycemic control (as measured by A1C), and provide patient satisfaction.

View this table:
  • View inline
  • View popup
  • Download powerpoint
Table 2.

Baseline Demographics of Class Participants

Insulin Pump Class Structure

Each class takes 90 minutes. All patients who have attended the class use the MiniMed Paradigm Revel insulin pump system, so the educational materials discussed during the session focus on this product. When patients arrive for class, a CDE downloads their insulin pump. While insulin pumps are being downloaded, another CDE begins the interactive educational roundtable, which focuses on insulin pump survival skills. Topics for the roundtable include:

  • Advanced carbohydrate counting using food models

  • Battery changing and adjustment of pump settings

  • Diabetic ketoacidosis prevention

  • Troubleshooting unexplained high blood glucose levels

  • Prevention and treatment of hypoglycemia

  • Infusion site care: infusion set types and sites and infection prevention

Although these topics are discussed during the initial insulin pump training, material is covered in more depth in class, and participants can share their experiences. In addition to these discussions, patients are also given survival skills kits that contain written handouts about these topics to enforce learning. The kits also contain glucose tablets, a diabetes driver decal, and a bag of U-100 insulin syringes. After the roundtable discussion, adjustments to insulin pump settings are made as needed with CDEs and each patient individually. Patients are given a copy of their insulin pump settings.

As the class comes to an end, patients complete a post-class satisfaction survey and are given a follow-up appointment.

Outcomes

As the class was developed, the initial goal was to enroll six insulin pump patients every 6–8 weeks, with the first session to be held in July 2011. From July 2011 to May 2013, 10 sessions have been held, with a total of 30 participants completing the class. Although the initial goal was to have six insulin pump patients per class, actual class size has varied from two to six participants (Table 3). The outcomes data collected for the class included pre- and post-class A1C values, pre- and post-class emergency room visits, and post-class satisfaction (Tables 4, 5 and 6).

View this table:
  • View inline
  • View popup
  • Download powerpoint
Table 3.

Insulin Pump Class Attendance

A1C results

The average pre- and post-class A1C levels were calculated based on the pre- and post-class A1C levels for each participant. As demonstrated in Table 4, the overall average pre-class A1C has been 7.4%, with an overall average standard deviation of 0.44. The overall average post-class A1C has been 7.2%, with an overall average standard deviation of 0.2.

Emergency room visits

The initial assessment of emergency room visits was the number of visits in the 12 months before the class date. For the 35 patients enrolled in the class, there had been a total of four emergency visits, two of which were diabetes-related. Tracking of post-class emergency room visits is ongoing. To date, there has been only one emergency room visit by a class participant, and that visit was diabetes-related.

Satisfaction survey

Participants who completed the survey in the class found the roundtable discussions, handouts, and visual aids to be helpful. The majority of participants who completed the survey (92.9%) learned at least one new skill for their insulin pump therapy. All respondents felt that what they learned will help them manage their insulin pump therapy and that their questions were answered. All survey respondents agreed to put their survival kit together and said they would recommend the class to others (Tables 5 and 6).

Challenges and Ongoing Development

Although these results indicate that the class has been successful, there are several limitations. The sample size for the class is relatively small. Additionally, the timeframe for measuring the impact of the class on A1C level and number of emergency room visits has been short. Overall, participants in this class were already compliant to their insulin pump therapy regimen.

View this table:
  • View inline
  • View popup
  • Download powerpoint
Table 4.

Differences in Participants' Pre- and Post-Class A1C Levels

View this table:
  • View inline
  • View popup
  • Download powerpoint
Table 5.

Class Participant Post-Class Survey, Part A (n = 28)*

View this table:
  • View inline
  • View popup
  • Download powerpoint
Table 6.

Class Participant Post-Class Survey, Part B (n = 28)*

CDEs are working to identify additional pump patients to enroll in the class, with the ultimate goal of having all insulin pump patients in the medical practice complete the course to improve glycemic control (as indicated by the A1C), reduce the number of diabetes-related emergency room visits, and ensure patient satisfaction with the class. The CDE team is also considering the addition of insulin pump “happy hours” on Friday afternoons as a drop-in option for patients who are unable to attend the scheduled class.

Footnotes

  • Sara Wilson Reece, PharmD, CDE, BC-ADM, is an assistant professor of pharmacy practice at the Philadelphia College of Osteopathic Medicine, Georgia Campus, School of Pharmacy, in Suwanee, Ga. She also provides diabetes clinical services for The Longstreet Clinic in Gainesville, Ga. Cheryl Lynn Hamby Williams, RN, CDE, is a diabetes educator with The Longstreet Clinic.

  • American Diabetes Association(R) Inc., 2014

References

  1. ↵
    1. Fernandez MP,
    2. Marcus AO
    : Insulin pump therapy: acceptable alternative to injection therapy. Postgrad Med 99:125–132, 141–144, 1996
  2. ↵
    1. American Diabetes Association
    : Standards of medical care for patients with diabetes mellitus—2013. Diabetes Care 36 (Suppl.1):11–66, 2013
    OpenUrlFREE Full Text
  3. ↵
    1. Neithercott T
    : Insulin pumps. Diabetes Forecast 65:50–53, 2012
    OpenUrlPubMed
  4. ↵
    1. Keen H,
    2. Pickup J
    : Continuous subcutaneous insulin infusion at 25 years. Diabetes Care 25:593–598, 2002
    OpenUrlAbstract/FREE Full Text
  5. ↵
    1. Rubin RR,
    2. Peyrot M
    : Patient-reported outcomes and diabetes technology: a systemic review of literature. Pediatric Endocrinol Rev 7 (Suppl. 3):405–412, 2010
    OpenUrl
  6. ↵
    1. Jackisch BI,
    2. Wagner VM,
    3. Heidtmann B,
    4. Lepler R,
    5. Holterhus PM,
    6. Kapellen TM,
    7. Vogel C,
    8. Rosenbauer J,
    9. Holl RW
    : Comparison of continuous subcutaneous insulin infusion (CSII) and multiple daily injection (MDI) in pediatric type 1 diabetes: a multicentre matched-pair cohort analysis over 3 years. Diabet Med 25:80–85, 2008
    OpenUrlPubMedWeb of Science
    1. Hoogma RP,
    2. Hammond PJ,
    3. Gomis R,
    4. Kerr D,
    5. Bruttomesso D,
    6. Bouter KP,
    7. Wiefels KJ,
    8. de la Calle H,
    9. Scchweitzer DH,
    10. Pfohl M,
    11. Torlone E,
    12. Krinelke LG,
    13. Bolli GB
    : Comparison of the effects of continuous subcutaneous insulin infusion (CSII) and NPH-based multiple daily injections (MDI) on glycemic control and quality of life: results of the 5-nations trial. Diabet Med 23:141–147, 2006
    OpenUrlCrossRefPubMedWeb of Science
    1. Doyle EA,
    2. Weinzimer SA,
    3. Steffen AT,
    4. Ahern JA,
    5. Vincent M,
    6. Tamborlane WV
    : A randomized, prospective trial comparing the efficacy of continuous subcutaneous insulin infusion with multiple daily injection using insulin glargine. Diabetes Care 27:1554–1558, 2004
    OpenUrlAbstract/FREE Full Text
    1. Hirsch IB,
    2. Bode BW,
    3. Garg S,
    4. Lane WS,
    5. Sussman A,
    6. Hu P,
    7. Santiago OM,
    8. Kolaczynski JW
    : Continuous subcutaneous insulin infusion (CSII) of insulin aspart versus multiple daily injection of insulin aspart/insulin glargine in type 1 diabetic patients previously treated with CSII. Diabetes Care 28:533–538, 2005
    OpenUrlAbstract/FREE Full Text
    1. Raskin P,
    2. Bode BW,
    3. Marks JB,
    4. Hirsch IB,
    5. Weinstein RL,
    6. McGill JB,
    7. Peterson GE,
    8. Mudaliar SR,
    9. Reinhardt RR
    : Continuous subcutaneous insulin infusion and multiple daily injection therapy are equally effective in type 2 diabetes: a randomized, parallel-group, 24-week study. Diabetes Care 26:2598–2603, 2003
    OpenUrlAbstract/FREE Full Text
  7. ↵
    1. Tamborlane WV,
    2. Sherwin RS,
    3. Genel M,
    4. Feliq P
    : Reduction to normal of plasma glucose in juvenile diabetes by subcutaneous administration of insulin with a portable infusion pump. N Engl J Med 300:573–578, 1979
    OpenUrlCrossRefPubMedWeb of Science
  8. ↵
    1. DCCT Research Group
    : The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin dependent diabetes mellitus. N Engl J Med 329:977–986, 1993
    OpenUrlCrossRefPubMedWeb of Science
  9. ↵
    1. Bode BW,
    2. Davidson PC,
    3. Fredrickson LP,
    4. Gross TM,
    5. Sabbah HT
    : Diabetes management in the new millennium using insulin pump therapy. Diabetes Metab Res Rev 18 (Suppl. 1):S14–S20, 2002
    OpenUrl
  10. ↵
    1. Nielson S,
    2. Kain D,
    3. Szukizik E,
    4. Dhindsa S,
    5. Garg R,
    6. Dandona P
    : Use of continuous subcutaneous insulin infusion pump in patients with type 2 diabetes mellitus. Diabetes Educ 31:843–848, 2005
    OpenUrlAbstract/FREE Full Text
  11. ↵
    1. Wittlin S
    : Treating the spectrum of type 2 diabetes: emphasis on insulin pump therapy. Diabetes Educ 32:39S–46S, 2006
    OpenUrlFREE Full Text
  12. ↵
    1. Wainstein J,
    2. Metzger M,
    3. Wexler,
    4. Cohen J,
    5. Raz I
    : The use of continuous insulin delivery systems in severely insulin-resistant patients. Diabetes Care 21:1910–1914, 1998
    OpenUrlAbstract/FREE Full Text
  13. ↵
    1. Scheiner G,
    2. Sobel RJ,
    3. Smith DE,
    4. Pick AJ,
    5. Kruger D,
    6. King J,
    7. Green K
    : Insulin pump therapy: guidelines for successful outcomes. Diabetes Educ 35 (Suppl. 2):29S–41S, 2009
    OpenUrlAbstract/FREE Full Text
View Abstract
PreviousNext
Back to top
Diabetes Spectrum: 27 (2)

In this Issue

May 2014, 27(2)
  • Table of Contents
  • Table of Contents (PDF)
  • Index by Author
Sign up to receive current issue alerts
View Selected Citations (0)
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word about Diabetes Spectrum.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Insulin Pump Class: Back to the Basics of Pump Therapy
(Your Name) has forwarded a page to you from Diabetes Spectrum
(Your Name) thought you would like to see this page from the Diabetes Spectrum web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Insulin Pump Class: Back to the Basics of Pump Therapy
Sara Wilson Reece, Cheryl Lynn Hamby Williams
Diabetes Spectrum May 2014, 27 (2) 135-140; DOI: 10.2337/diaspect.27.2.135

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Add to Selected Citations
Share

Insulin Pump Class: Back to the Basics of Pump Therapy
Sara Wilson Reece, Cheryl Lynn Hamby Williams
Diabetes Spectrum May 2014, 27 (2) 135-140; DOI: 10.2337/diaspect.27.2.135
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • Program Background
    • Insulin Pump Class Structure
    • Outcomes
    • A1C results
    • Emergency room visits
    • Satisfaction survey
    • Challenges and Ongoing Development
    • Footnotes
    • References
  • Figures & Tables
  • Info & Metrics
  • PDF

Related Articles

Cited By...

More in this TOC Section

Departments

  • Smart Connected Insulin Pens, Caps, and Attachments: A Review of the Future of Diabetes Technology
  • Brief Literature Review: The Potential of Diabetes Technology to Improve Sleep in Youth With Type 1 Diabetes and Their Parents: An Unanticipated Benefit of Hybrid Closed-Loop Insulin Delivery Systems
  • Finding My Diabetes Community
Show more Departments

Pharmacy and Therapeutics

  • Cannabidiol (CBD) Use in Type 2 Diabetes: A Case Report
  • Injection-Site Nodules Associated With Once-Weekly Subcutaneous Administration of Semaglutide
  • Glucagon Therapy: A Comparison of Current and Novel Treatments
Show more Pharmacy and Therapeutics

Similar Articles

Navigate

  • Current Issue
  • Papers in Press
  • Archives
  • Submit
  • Subscribe
  • Email Alerts
  • RSS Feeds

More Information

  • About the Journal
  • Instructions for Authors
  • Journal Policies
  • Reprints and Permissions
  • Advertising
  • Privacy Policy: ADA Journals
  • Copyright Notice/Public Access Policy
  • Contact Us

Other ADA Resources

  • Diabetes
  • Diabetes Care
  • Clinical Diabetes
  • Scientific Sessions Abstracts
  • Standards of Medical Care in Diabetes
  • BMJ Open - Diabetes Research & Care
  • Professional Books
  • Diabetes Forecast

 

  • DiabetesJournals.org
  • Diabetes Core Update
  • ADA's DiabetesPro
  • ADA Member Directory
  • Diabetes.org

© 2021 by the American Diabetes Association. Diabetes Spectrum Print ISSN: 1040-9165, Online ISSN: 1944-7353.