Patient -Centered Care of the Pregnant Patient with Diabetes Who Uses an Insulin Pump During Labor and Delivery

Purpose for the program:

Continuous subcutaneous insulin infusion (CSII) pump therapy is associated with better quality of life and in some studies better glucose control than  standard multiple dose insulin injections. A person with diabetes who uses an insulin pump for blood glucose management considers the insulin pump as a lifeline. Disconnecting from the insulin pump raises concern and triggers unnecessary anxiety. Most of our patients were told to discontinue their pumps on admission to Labor and Delivery. Sometimes a physician would write an order to allow a patient to continue using the pump which was problematic because no supervision of insulin delivery or assessment of the patient’s ability to manage the pump was taking place by nursing staff or physicians.  The obstetricians weren’t familiar with the intricacies of dosing and need for quick, abrupt changes in postpartum dosing.

Proposed change:

Partnering with the Director of our Diabetes and Obesity Institute, a pump pilot program was initiated with tools and guidelines unique to the obstetrical setting. The most important component of this patient-centric journey was utilization of an Insulin Pump Agreement.  Because these patients make daily insulin dose adjustments independently, it was critical to empower both the pump-using patient and nurse to form a partnership concerning insulin dosing during hospitalization. The agreement addressed the following key points:

• Showing the nurse bolus and basal rates and changes
• Frequency of infusion set and infusion site changes
• Reporting symptoms of hypoglycemia and pump problems
• Situations when the pump may need to be discontinued

Implementation, outcomes and evaluation:

Standardized orders for insulin pump therapy management in the intrapartum and immediate postpartum periods were developed, along with a Medication Administration Record allowing for documentation of basal rates and boluses.  All pump patients have an endocrine consult to assess ability to manage self care and determine post partum dosage changes.  Mandatory education sessions for all nurses, midlevel providers, and physician staff were provided by our Diabetes Nurse Clinicians. The sessions addressed technical aspects of CSII pump therapy and the patient’s emotional connection to the pump. The Nurse Clinicians are notified when a patient using an insulin pump is admitted and  assist nurses and providers with any process issues.  Data collection and outcomes evaluation are ongoing with changes being made as relevant.

Implications for nursing practice:

Nursing has been essential in the formation of a multidisciplinary team partnering to provide safe, effective and patient centered care.

Keywords: continuous subcutaneous insulin infusion pump; Type 1 diabetes in pregnancy; insulin pump patient agreement; patient centered care