for the patient. Medicare covers a pump for a patient with type 1 or type 2 diabetes who (A) has completed a comprehensive diabetes education program, performs at least 4 daily SMBG checks, uses at least 3 injections per day, and meets one or more other glycemic control-related criteria; OR (B), if a patient has been on a pump prior to enrollment in Medicare and has documented frequent (minimum of 4 daily) SMBG checks during the month preceding enrollment and meets one or more other glycemic control-related criteria. Additionally, a prospective or current pump patient must have a documented fasting C-peptide level ≤110% of the lower limit of normal of a lab’s range (e.g., up to and including 0.99 ng/ml, if the low range is 0.9 ng/ml) or be beta-cell autoantibody positive for Medicare insulin pump coverage. The positive autoantibody test allows patients with latent autoimmune diabetes in adulthood (LADA), referred to as type 1.5 diabetes, to qualify for a pump. Always confirm current Medicare coverage. The pump must be ordered by and follow-up care must be managed by a physician who manages multiple pump patients and who works closely with a team, including CDEs, RDs, and nurses who are knowledgeable in use of pump therapy (DHHS 2013).
• Is capable intellectually, physically, and technically. A patient contemplating pump therapy must be able to demonstrate an understanding of the therapy. Intellectually, the patient must demonstrate understanding of insulin-to-carbohydrate ratios and correction (sensitivity) factors and the applications of these parameters to determine appropriate insulin bolus doses. The ability to insert the pump battery(ies), fill and/or place the insulin cartridge/reservoir into the pump, insert the infusion set, wear the pump, and perform the technical functions of the pump is essential.
« Patients with moderate to severe hand arthritis or neuropathy may not be able to press the pump’s buttons or remote device or handle the insulin cartridge/reservoir and infusion sets.
« Patients who are blind or visually impaired may be limited in their choice of pump because of a lack of audio functions or small screen displays.
« Patients who are deaf or hearing impaired may be at greater risk for interruptions in insulin delivery because they have difficulty hearing the pump’s alarm. Pumps with vibrating alarms may be essential.
• Demonstrates emotional stability. The pump patient must routinely attend education sessions and attend to tasks that require routine. A patient with untreated depression, eating disorders, manipulative behavior, or other psychoses is usually ill-suited for pump therapy. Carefully assess the pump candidate’s psychological status, or refer the patient to a mental health professional. Suggest treatment options for behaviors that may interfere with pump therapy.
Young or old, age in itself is not necessarily a contraindication to successful pump therapy. Children as young as newborns and people in their 70s have had success with pump therapy.
The patient’s education level is not a deciding factor in pump therapy. However, diabetes knowledge and an understanding of the relationship between insulin and food, stress, and exercise are key factors in assuring successful pump therapy.
Contraindications: Red Flags
Why the Patient Isn’t Ready for Pump Therapy
Although pump therapy does not increase the risk of mortality among its users, the frequency of adverse events increases with:
• Poor candidate selection
• Infrequent SMBG
• Insufficient or inadequate supervision and monitoring by the diabetes healthcare professional or team
• Inexperienced pump therapy practitioners
Indications that the Patient Is Not an Appropriate Candidate
There can be numerous reasons why a patient may not be an appropriate candidate for pump therapy. However, this doesn’t mean the patient may not ever be ready for an insulin pump. Behavioral changes, diabetes knowledge, and maturity in dealing with diabetes challenges come with time and education. Be aware that any of the concerns below can be corrected, thus improving the patient’s readiness to take on pump therapy:
• Complains of performing frequent blood glucose checks: thinks that pump therapy reduces or omits the need to perform SMBG
• Is “tired of meal planning,” counting carbohydrate, and calculating mealtime insulin doses: believes that the pump automatically calculates necessary bolus doses without any user input
• Does not want to carry any “diabetes supplies,” e.g., back-up injection device, insulin, hypoglycemia treatment (and when using pump therapy, spare infusion sets)
• Doesn’t understand the causes, prevention, and treatment of hypoglycemia
• Is not aware of glucagon and doesn’t have a plan for its use (i.e., a family member or significant other trained in the administration of glucagon)
• Doesn’t understand the causes, prevention, and treatment of hyperglycemia
• Is not aware of ketone strips, does not have ketone strips, or does not know when/how to check for ketones
• Lives alone and does not have a readily accessible support team (family, friends, coworkers, access to emergency services)
• Has evidence of a psychiatric disorder, including severe or recurrent depression, severe eating disorder, or a history of attempted suicide
• Lacks insurance or means to pay for an insulin pump and pump supplies
Steps for Helping the Patient Determine and Achieve Readiness
You may be able to identify good candidates for insulin pump therapy, but patients still need to decide whether pump therapy is for them. Here is an education plan for helping the patient make this decision.
1. Give the patient a general overview of what pump therapy entails. Discuss the advantages and challenges, as well as realistic goals and expectations for pump therapy.
2. Review the prospective pump user’s medical history and evaluate his or her diabetes knowledge. Consider using written pre- and post-tests.
3. Demonstrate how an insulin pump works (bolus delivery). Explain basic pump therapy terms, including basal rate, bolus dose, infusion set, infusion sites, dressing, and insulin cartridge/reservoir. Show available models, and encourage the patient to learn the features offered by each brand of pump. Explain that he or she can disconnect the pump for bathing, intimacy, and intensive sports.
4. Have the patient handle a pump. Some patients mistakenly believe the pump is worn only during the day and removed at bedtime. Others believe an insulin pump is surgically implanted or permanently attached. Most people are surprised to learn how small a pump is and how it is worn.
5. Show the differences between a pump that uses tubing that connects to an infusion site and a pump that is worn without tubing and is directly connected to the body.
6. Show the available infusion sets. Explain that tubing (if applicable) is available in various lengths to accommodate where the pump is worn. Explain how a pump with tubing can be worn in and under clothing, such as in a pocket, sock, or bra. Show pump accessories, such as clips, leather cases, fanny bag–type cases, clothing with built-in pump pouches or pockets, and Velcro-attached removable pockets or small (infant-sized) socks. Show appropriate sites for wearing a “patch” pump that does not require tubing.
7. Demonstrate the insertion and removal of an infusion set. Demonstrate an infusion set inserter device, if appropriate. Allow the patient to practice a self-insertion. There is a commercially available injection pad, or “rubber belly,” that attaches to the patient’s abdomen, thigh, or upper arm with an adjustable strap. Does the patient want to wear an infusion set for a few days to get accustomed to the feel of it? If possible, offer the option of wearing a demo pump with saline for a few days to determine how the patient likes that particular pump and pump therapy in general (see Optional Saline Trial). When parents are considering pump therapy for their child, this experience sometimes results in postponing