Insulin Pump Start-Up Training

Prescriber Sign-Off for Insulin Pump Start-Up Training

Insulin pump start-up education (“pump training”) takes 1-3 hours and should be done in an outpatient setting, such as the prescriber/specialist’s office. Pump manufacturers employ or contract with health care professionals (RDs, RNs and PharmDs) who are usually CDCES certified by the pump manufacturer as a certified pump trainer (CPT). CPTs provide pump training services, following the prescribing physician’s pump start orders.

The prescriber is responsible for providing/signing off on pump start orders to the diabetes care and education specialist or designated pump trainer assigned to provide the pump start-up training.

These include:

• Starting basal rate(s)
• Insulin-to-carbohydrate ratio(s) (ICR)
• Target blood glucose level(s)^10,11
• Correction (or sensitivity) factor(s) and instructions for use
• Duration of insulin action (“insulin on board” or “active insulin time”)
• Self-monitoring of blood glucose (SMBG) instructions or utilization of a CGM device
• Communication guidelines, i.e., who, when and where the patient contacts for reporting glucose results, asking for diabetes management assistance (specialist/prescriber) and asking for technical assistance (pump manufacturer/CDCES)
• Understand how to upload the device and provide data to the provider/CDCES
• Determine who is available 24/7 to cover medical management questions that may arise.⁴

The specialist should carefully set the pump startup date, assuring that the individual’s first few weeks of pump therapy are planned during “normal routine” days, avoiding situations or conditions that may adversely affect blood glucose levels or interfere with the establishment of basal rates.⁹

Start-up orders should be provided to the individual several days in advance and should include:

• 24-48 hour pre-pump adjustments in insulin injection therapy
• Glucose history either through meter or CGM data upload
• A list of supplies to bring to the pump start-up appointment
• Specific information regarding appointment time and location⁹

The pump wearer must also learn the technical components of their pump, including how to:

• Insert or charge the battery
• Fill and insert the insulin cartridge/reservoir
• Insert and change the infusion set and tubing (if applicable)
• Input information for the pump to calculate appropriate insulin dosages
• Program basal rate changes
• Review the pump history. With advances in sensor-integrated insulin pumps, a thorough understanding of the automated systems and the potential to revert to manual mode is needed. Most manufacturers require that training on their pump is conducted by a health care provider certified by the manufacturer as a pump trainer (“CPT”). A pump start is best conducted at a time in the day and on the day(s) of the week when the managing health care professional is available for medical management following the pump initiation.

Specific instructions for follow-up and management during the first few weeks after pump start-up should include: Frequent SMBG, i.e. minimum of four to five times per day, i.e. 3:00 a.m., fasting, before each meal, 2 hours after meals and bedtime.

All SMBG readings should be entered into the pump. Generally, CGM glucose data should also be entered into the system, however there is one system at this writing that auto inserts the glucose reading and incorporates the data into the delivery system without input from the user.

• Limiting alcohol and high-fat foods
• Inputting all carbohydrate values
• Recording any additional insulin or carbohydrate intake outside of the dosing within the insulin pump (correctional factors for blocked cannula, carbohydrates for hypoglycemia) that would not otherwise be noted in the pump download
• Recording any unexpected or unusual events that could affect blood glucose levels, e.g., stress or illness, unusual exercise routine as well as the onset of menses
• Instructions to upload or e-mail the information to the diabetes care and education specialist as agreed upon, generally initially daily
• Reminders to call the pump manufacturer’s support service with questions or problems related to the technical functions of the pump if the diabetes care and education specialist is not available

Follow Up

A follow-up visit should occur within one week after start-up. This allows for the opportunity to review and observe an infusion set or pod site change, remove pump syringe/cartridge, filling and insertion. The individual should be in contact with the prescriber or CDCES/CPT within 2-4 weeks after the pump start-up for a review of insulin pump download data including glucose, dosing, compliance with infusion site changes, alarms and any overriding of the automated system. Review of infusion set sights and options should also occur.

Non-programmable insulin patch pumps are also available. These systems have a fixed basal rate (different rates available) along with an option for bolus delivery. The dosing is not integrated into the pump but is at the discrepancy of the wearer. Data from these pumps is not downloadable at this time.

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References:

^{American Diabetes Association. Standards of Medical Care in Diabetes—2024. Diabetes Care. ADCES Insulin Pump Therapy Guidelines, ISPAD Clinical Practice Consensus Guidelines 2022: Insulin Pump Therapy. Endocrine Society. Management of Continuous Subcutaneous Insulin Infusion (CSII) and Continuous Glucose Monitoring (CGM). Clinical Research on Insulin Pumps & Automated Insulin Delivery (AID) Systems: Beck RW, Riddlesworth T, et al. Effect of Continuous Glucose Monitoring on Glycemic Control in Adults With Type 1 Diabetes Using Insulin Injections: The DIAMOND Randomized Clinical Trial. JAMA, 2017.}