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Editorial response to New Standards for Safer Insulin Pump Use Needed

May 20, 2008

Lois Love Exelbert, RN, MS, CDE, BC-ADM Administrative Director, Diabetes Care Center Baptist Hospital of Miami

Safety of insulin pumps, even in adolescent use, is dependent on thorough evaluation, patient selection and education

I found the report presented by Cope et al, to be interesting but fear that the possible conclusions a reader might draw could deprive many of the benefits of pump technology, particularly adolescents.   The reasons are:

1Combining a report about insulin pumps and PCA pumps presumes technology as the primary focus.  This is far too simplistic.   There is little similarity between adolescents who may need patient controlled analgesia to those with a chronic disease needing insulin to sustain their lives!  We have assisted children, adolescents and adults to use insulin pumps ever since the inception of this technology.  They have all done well but it is an involved process.

2.Within this study there is no analysis of the type of education received by the adolescents studied – only that "education" was one of the factors that may have contributed to adverse events.  For example, we require a very stringent and multifaceted evaluation, along with education prerequisites before finally scheduling a patient, and family members, for an all-day pump initiation. 

3.Many factors must be taken into account before placing a person on an insulin pump.  First, their commitment to the rigors of living with diabetes such as (but not limited to) testing blood glucose many times a day (no pump at this time will automatically do that), counting carbohydrates to administer appropriate mealtime doses of insulin, successful approximation of the effects of exercise and successful recognition and treatment of hypoglycemia.  Beyond that,  there’s the emotional, psychological and capability evaluation – all this before even beginning to teach the actual button-pushing or hands-on technology of preparing, inserting and programming an insulin pump.

This is an expensive device usually covered by third party payors but  none that we are familiar with has ever required a thorough evaluation at a center for diabetes education by Certified Diabetes Educators prior to authorization.  The presumption that this is adequately handled by the physician who writes the prescription or by the company that sells the pump is erroneous.   As stated earlier, there is a multiplicity of factors besides technological adeptness in treating diabetes patients.  Fortunately we work with physicians who recognize the importance of diabetes education center involvement and our patients have done well.   In contrast, we have seen horrendous pump habits in patients who come to us for the first time who were merely taught button-pushing initially. 

Example: Would you employ someone to take your appendix out who was simply taught the technique or would you require that this person went to medical school first? 

In conclusion, it is unfortunate that questions such as the type (or lack) of education were not asked in this report.  In addition, maybe we can suggest that insurance companies protect their investment and require a "pump certification" before covering these type devices.   Perhaps insulin pump companies might realize that it is in their financial, legal and ethical interest to require such a certification and not be so eager to "sell" their product to anyone who asks for it. Not only might we reduce the exorbitant cost of healthcare by doing this, we might also save a few lives!  What a unique thought!

Lois Love Exelbert, RN, MS, CDE, BC-ADM Administrative Director, Diabetes Care Center Baptist Hospital of Miami