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Chapter 2 Pump and Infusion Set Options and Selection

Karen M. Bolderman, RD, LDN, CDE

Susan L. Barlow, RD, CDE

Pump Features

Several manufacturers sell insulin pumps and infusion sets. A pump company may offer more than one model. Each pump has slightly different features. And there are many different types of infusion sets available for pumps that are connected to the patient with an infusion set (versus a “patch/pod/tubeless” pump).

What kind of pump—standard with tubing and infusion set or “patch”/pod? A pump that is totally “contained,” or one that has a disposable component to it? The latter style pump’s settings are programmed into the “hardware” part of the pump and the section of the pump containing a pre-filled insulin cartridge is connected to the main component section, used for several days (with tubing attached to the person’s body), removed, and replaced, thus saving on the initial financial investment. There are many different pump brands and models to choose from.

Most pumps connect to the body via tubing of various lengths and an infusion set. A patch/pod or “tubeless” pump system consists of an integrated glucose meter and remote control device to operate the insulin “pod,” which is attached to the skin similarly to an insulin infusion set with self-adhesive tape. An insulin pod is a combination of an insulin pump cartridge/reservoir and infusion set. The patient fills the pod with the amount of insulin to be infused over several days and attaches the pod via the built-in cannula. A patch/pod pump eliminates the need for tubing, as the infusion set and pod holding the insulin are an integrated system. The pod delivers the insulin using the remote control device that is programmed with the user’s pump settings, such as basal rates, bolus options, etc. Some models provide the option of delivering a bolus directly from the pod.

After 2–3 days’ use, the pod is disconnected from the skin and discarded, and replaced with a new pod that the pumper again fills with the appropriate amount of insulin. A pod is shaped similarly to a small half hard-cooked egg and is attached to the body with self-adhesive tape. Once in place, it is not “moveable,” as there is no tubing. Patch or “pod”-style pumps provide another option in pump therapy without the “hassle” factor of tubing. Many people prefer the freedom that a tubeless pump allows, while other people may not like the “immovable lump” appearance of the patch pump and might prefer to “move the pump around” and wear it outside or inside clothing. Of course, pod placement can be as discreet as wearing a tubing-style pump under the clothing.

Insulin Pump Options and Selection

Experience with one brand of pump may bias a physician or educator toward that pump even when another brand or model may suit the patient as well, or better. Sometimes clinicians assume that their personal preferences for pump features are the same as the patient’s. As much as possible, allow the patient to choose their pump. Remember that you are preparing and managing the patient’s pump therapy, NOT training the patient on the “buttonology” or button-pushing aspects of the pump. Don’t allow your personal pump brand choice, bias, or comfort level with a particular brand dictate the pump the patient chooses. The patient’s preference is paramount and can be a factor in successful implementation of pump therapy.

Deciding on a suitable choice usually takes time. Give the patient enough time to read the marketing literature, surf the various pumps’ websites (some have “virtual” interactive pumps to simulate use/practice), view the various pump manufacturer DVDs, review diabetes publications comparison lists and articles about pumps, and meet with the pump manufacturer sales representatives and/or clinical staff. As the prescribing clinician, if you have been provided with several manufacturers’ “demo pumps,” offer to demonstrate several pumps to the patient. This may be helpful after the patient has done some research and is able to discuss features that appeal to them. Remember that, like all cars that get you from one place to another, all pumps deliver insulin but vary in their colors, options, features, and degree of sophistication.

Pump Criteria Checklist

General

Is the pump a patch/pod type, eliminating the need to be “connected” to infusion set tubing 24/7 but requiring a remote device or wireless device/meter combination for all programming?

Does the pump have advanced programming features that would be used for “fine-tuning” basal and bolus delivery and be implemented over time? Some pumps are sophisticated or “smart” and have options for fine-tuning insulin, while other pumps offer basic basal–bolus features that may be more appropriate for a person with type 2 diabetes who would not use the sophisticated, more advanced “smart pump” features.

• Ease of navigating on-screen selections (user “friendliness” or intuitive use) Does the pump utilize touch-screen technology and/or have minimal button pressing and scrolling?

• Is the pump screen easily visible? Does it have color and/or contrast making it easy to see and operate under a variety of light conditions?

• Use of icons, words, or abbreviations (and color)

• How much memorization is required? Is it difficult to remember how to move from one screen or function to another?

• For a child, could someone only slightly familiar with the pump (caregiver, teacher, babysitter) stop it or perform troubleshooting? Is there a lock feature and/or remote control?

• Ease of manual tasks: Could a user with hand arthritis, carpal tunnel syndrome, or neuropathy use the pump easily?

• Does the user need to fill the cartridge/reservoir with insulin or does the pump use brand-specific pre-filled cartridges? Are there many steps in “loading” the cartridge/reservoir into the pump?

• How many steps are involved in changing or entering a program?

• Can the pump user choose between hearing audible sounds and alarms (in varying sound volumes) and a vibratory mode for all pump functions?

• How long does the battery(ies) last? Are batteries easy to obtain and replace? Does the pump require charging and how often? How easy is it to replace a lost charger or obtain a back-up charger?

• Does the pump have a specific infusion site/set change reminder alert or alarm that can be programmed to sound or vibrate at a time chosen by the user every 2–3 days (or as determined appropriate) to serve as the reminder to change the infusion set/site? This is one of the most useful features ever designed for insulin pumps. A “general” or non-specific alarm that can be set for whatever reason the pump user decides is not nearly as useful. The importance of changing the infusion site/set often cannot be stressed enough to new as well as experienced pumpers.

• What type of clock is available, 12-h or 24-h? Does the pump have the option for both 12-h and 24-h? This is important, as patients who use the 12-h clock may inadvertently switch AM to PM and deliver the wrong basal doses throughout the day. Downloaded history may not alert the patient to this error. Most pumps today offer both clock options, but basal rates are most accurately programmed using the 24-h clock.

• Does the pump have multi-language capacity?

• What is involved in detaching the pump?

• Does the pump have a backlight? How long does the backlight stay lit, and is the duration of time adjustable?

• Is the pump waterproof or watertight? Does it require any special accessories to make it waterproof? This is a consideration not just for water sports, as daily activities also expose the pump to water, such as accidentally dropping the pump into the toilet or using it in the shower/bath.

• What is the size of the pump? How thin is the pump? Can it be worn discreetly under clothing?

• How much does the pump weigh?

• Does the pump have the option of using a remote device for all its programming and delivery functions?

• Is there an audio, vibrate, or remote option for patients who want to wear the pump discreetly?

• How is a patch/pod/tubeless pump attached to the person? How strong is the adhesive? Can the pod be temporarily disconnected?

• How is a standard pump with tubing worn/attached to the person? Are there options, including a removable clip, a case with a built-in clip, a case with built-in belt loops, or a choice of other cases? Is the case available in a variety of colors and materials (leather, vinyl, plastic, etc.)? Do case options include something like a “skin” used on cell phones to provide a grip and ease in holding the pump? Will the pump fit into a “universal” case, i.e., one that accommodates various pumps so that the patient may be able to purchase a case from another pump manufacturer?

• Is the pump available in more than one color? If not, can the user change the outside color or appearance of the pump?

• With what device can the pump communicate? Most insulin pumps can wirelessly communicate with either a blood glucose (BG) meter or a continuous glucose monitor (CGM). As of this writing, interconnectivity among all three devices is not yet available, but the integration of these technologies is on the horizon. Determine what is most important for the patient—the ease of wireless transmission of the BG from the meter to the pump for calculation of insulin doses, or use of a CGM device.

• What types of history does the pump store? Percentage of total daily dose (TDD) as basal and as bolus? Most recent boluses? A summary of daily delivery, including TDD, an average of TDD over X number of days, amounts of insulin delivered as correction boluses and meal boluses, infusion set changes? Total history, including alarms, alerts, battery changes, infusion set changes, and basal rate/pattern changes?

• Does the pump include software to download data reports of various types that can be used by both the patient and healthcare professional to track trends, make changes and corrections, and monitor overall use of the pump?

Insulin and insulin delivery

• What size is the cartridge/reservoir, i.e., how much insulin can it hold? Does the pump use a disposable cartridge/reservoir, or is the cartridge “built into” the pump? How much insulin can the cartridge/reservoir hold? This varies, and as of this writing ranges from 176 units to 315 units. This is important for people who are insulin resistant or use large doses of insulin. Remember that tubing connects the cartridge/reservoir to the infusion set and the tubing must be primed (filled) with insulin with each infusion set change (see Sets with tubing). A set change occurs every 24–72 hours, and the amount of insulin (approximately 20 to 45 units depending on the tubing length) changed/wasted (from discarding the tubing) should be taken into consideration. This may increase overall costs of the insulin supply. Overall, this is an important consideration in choosing a pump whose cartridge/reservoir contains <200 units for use in a patient requiring >55–60 units/day.

• Some pumps make noise during basal and bolus deliveries. The noise can be a “clicking” or “zzzz-sounding” type noise. Does this matter to the user?

• Frequent insulin delivery is an important issue for infants, toddlers, children, and insulin-sensitive adults. If the infusion set cannula or metal/steel needle is not infusing insulin constantly, subcutaneous or scar tissue may build up and occlude the site, impeding basal delivery. In contrast to pumps with solenoid motors, a direct-current motor pump delivers fractions of any basal rate, no matter how high or low, in “micro” pulses every 3 minutes. Insulin-sensitive patients are better matched to direct-current motor pumps.

Basal rate delivery

• Does the basal rate deliver in increments of 0.10 (tenth of a unit), 0.05 (twentieth of a unit), or 0.025 (fortieth of a unit)? Smaller increments are useful for fine-tuning basal rate delivery in children and insulin-sensitive people.

• Can the user temporarily increase and decrease basal rate delivery, and for how long? Can the pump be programmed to automatically calculate increases or decreases in percentages for several different basal rates, or can it alternately just calculate the number of units or units/hour? A temporary basal increase is helpful for acute illness or preceding menstruation, whereas a temporary decrease in basal delivery is useful for exercise.

• How many 24-h basal rate programs can be programmed into the pump? This is useful for patients who want to accommodate activity levels that vary day-to-day. For example, if weekend activity levels are different from weekday activity levels, the user may want to pre-set different 24-h basal programs with higher or lower rates instead of frequently resetting temporary basal rates. The ability to set alternate 24-h basal programs is a helpful feature for children who have gym class on specific days, adults who exercise on alternate days, and patients who are shift workers or weekend athletes, and is also useful for times of premenstrual syndrome, stress, and illness.

Bolus delivery

• What types of bolus delivery options does the pump have? Is the bolus delivery increment in twentieths, tenths, halves, or whole-unit increments, or does the user have a choice? Patients who are insulin sensitive may prefer or require fractional-unit bolus increments.

• Is there more than one type of bolus delivery available? An extended (“square wave”) or combination immediate/extended (“dual wave”) bolus delivery is useful for patients with gastroparesis and also may be used when consuming high-protein, high-fat, or ethnic meals and if using pramlintide. How long can delivery be extended? Can the delivery be in increments of an hour, such as 15, 30, or 45 minutes?

• Is there a touch bolus button? Is it audio or vibratory? This is a consideration for the patient who prefers to wear the pump discreetly and does not want to visibly press buttons on the pump or use a remote device to deliver a bolus.

• Is there a remote device available to deliver a bolus?

• Can specific bolus types be “named” and programmed into the pump for ease of use, such as “pizza,” “ethnic meal,” “dessert”? This is helpful and alleviates the need to repeatedly program a frequently used combination (“dual wave”) bolus.

• How is “insulin on board” (active insulin) calculated for bolus deliveries, i.e., can the user determine the number of hours the most recent bolus is active, or does the pump automatically default to a specific duration of time setting, such as 4 hours? This is a useful feature to prevent “insulin stacking” for repeated correction boluses (see Use of Duration of Insulin Action “Insulin on Board” or “Active Insulin” Feature). How does the insulin on board feature account for the insulin dose required for the upcoming meal?

• Does the pump store a history of bolus deliveries? How many? Can this information be downloaded to track trends and patterns of use and dosages?

Safety

• Can a bolus dose be stopped easily during delivery? Can the user track exactly how much of the bolus was delivered before it was halted?

• Is there a maximum use lockout feature for children, so that a basal rate or bolus delivery cannot be programmed for more than a specific upper limit?

• Is there a time-out feature that the user can pre-set to halt all insulin delivery if a button is not pushed for a specific duration of time?

• Can the user set an hourly limit of insulin delivery?

• What type of safety and performance checks does the pump have? How often does the pump perform self-checks?

• What types of warning and alarm systems does the pump have? Is there an alarm for undelivered basal insulin?

• Does the pump alarm sound/vibrate when insulin is running low or the cartridge/reservoir is empty? How is the amount indicated? Is it approximate or exact?

• If batteries are removed for an extended period of time, does the pump retain its memory of programmed basal rates and history of bolus doses and alarms?

• Is the warning and/or alarm signal visual, auditory, or tactile? If audio, how loud is it? Patients may need a pump with vibrating warnings and alarms.

• In case of a major technical problem, is a backup pump provided? What are the procedures to obtain a backup pump if one is not provided at the time of purchase? How quickly does the patient receive the replacement pump?

• What is the repair policy? If the pump is returned for problems, is it repaired and reissued to the patient, or is a new pump provided? Are refurbished pumps redistributed?

Infusion Set and Tubing Options

Infusion sets distributed by the various pump and pump supply manufacturers may be interchangeable to work with several different brands of pumps or they may be proprietary and brand-specific. Some sets may be designed specifically for a particular age group, such as pediatric. It is best to check with each pump company for specific availability and recommendations and make sure your patient explores all the options with the assistance of the pump manufacturer.

An infusion set is inserted subcutaneously and the set “base” is attached to the insertion site with self-adhesive dressing or tape. An infusion set is worn for 1–3 days and then removed and discarded. Infusion sets left in longer can lead to infection and/or scarring, which slows insulin delivery. Although many brands exist, there are basically two types of infusion sets: metal/steel needle cannula and Teflon cannula, and both types are available in various models. Most infusion sets connect to an insulin pump using a Luer-lock connection, and thus are universal and can be used with a variety of pumps. Advise the potential pumper to be aware of pumps that use a proprietary infusion set, as their choice of infusion sets will be limited unless the pump has an adapter that allows it to accept a Luer-lock infusion set (Roche 2012).

A metal/steel needle infusion set is inserted at a 45- to 90°-angle and requires that the needle stay under the skin. The insertion base and tubing are attached to the site with either self-adhesive or separate dressing or tape. A metal/steel needle infusion set can be disconnected from the infusion site (close to the site or several inches from the site), thus providing lifestyle comfort for physical activity, bathing, and sexual activity. A variety of needles are available by type (straight or bent) and length. Children and lean adults may need shorter needles, and active people may need longer needles to guarantee subcutaneous insertion and placement. A metal/steel needle set may be appropriate for patients who have problems with kinking or dislodgment of Teflon cannula sets. A metal/steel needle set is made of surgical stainless steel and can contain up to 12% nickel and may not be appropriate for people who experience an allergic reaction to nickel or stainless steel (Roche 2012). Some people find the metal/steel needle sets to be uncomfortable because the needle may “pinch” or be felt during physical activity or movement. A metal/steel needle set should be changed every 24 to 48 hours (Roche 2012). A major advantage of the metal/steel needle infusion set is the guarantee of insulin delivery, as a metal/steel needle cannot kink below the skin like a Teflon cannula set. Many parents of child pumpers like them because they are easy to teach to the child’s teacher or babysitter in case the child’s usual cannula set becomes dislodged. Metal/steel needle infusion sets are also often recommended during pregnancy because they may be easier than a Teflon cannula to insert in the abdominal area or a “hard to reach” (such as the upper hip/buttocal) area and they guarantee insulin delivery with no risk of a kinked or bent cannula.

The metal/steel needle infusion sets had been in use for several decades when pumps were first introduced. They are generally less costly than the soft Teflon cannula sets but are not as commonly used today. Some people choose to alternate use of both types of sets depending on their activity or exercise.

An allergic reaction to the adhesive in the dressing or the glue used to manufacture the infusion sets can occur; trial and error with different products is recommended to determine individual sensitivity.

Because every person can react differently to infusion set material, suggest your patient try a variety of sets. Pump manufacturers and trainers may be able to provide a sample of a few different sets for the patient to try.

A soft Teflon cannula set uses a stainless steel introducer needle that is threaded into the cannula for a 20- to 90°-angle subcutaneous insertion, depending on the brand and the angle of the needle (angled 30 to 45° versus straight 90°). Teflon cannula sets are latex-free and do not contain PVC (polyvinyl chloride). After insertion the needle is removed (having been under the skin just a few seconds), leaving only the cannula below the skin and the infusion set base at the site. The set base has self-adhesive tape or dressing. With a 30°- to 45°-angled set, there is a clear “window” area in the self-adhesive tape, allowing visibility of the site of the catheter insertion. The clear window allows the user to detect the status of the site, including signs of redness or other problems. A 90°-angle set does not have a viewing window, and the user may not be aware of dislodgment or problems until hyperglycemia occurs. Some people find the length of a cannula infusion set introducer needle intimidating and require reassurance and practice in insertion. Some cannula infusion sets have an insertion device to help with insertion (see below). A cannula set can be more comfortable to wear than a metal/steel needle set because the patient cannot feel the set when bending, twisting, or exercising.

Teflon cannula sets may be straight or angled and come in different lengths ranging from 5.5 to 17 mm. The shorter lengths are typically inserted at a 90° angle, while the longer lengths are inserted at a 20 to 45° angle. A short cannula (5.5 or 6 mm) may have a higher failure rate in non-slender adults and probably should not be used initially except in slender patients. And cannula infusion sets come in a variety of models: some are stationary, while others can rotate or change position depending on how the user prefers the tubing to be directed (right or left side, upward or downward). Additionally, some manufacturers offer infusion sets in a choice of colors other than white/clear. New infusion set models are introduced fairly frequently; be aware of the latest available options.

Depending on the brand, a Teflon cannula set can be inserted manually, or with a built-in injector that is disposed after use, or an optional handheld device to facilitate insertion of the needle. Some people prefer the use of an injector system or device, while others may find the clicking noise bothersome. Over time, most patients develop a preferred angle of manual insertion and placement that cannot be determined with the use of an insertion device. Even if your patient chooses to use an insertion device, recommend the patient also learn manual set insertion in case the inserter device is unavailable or becomes lost or broken. No matter what type of infusion set is used, the set should be inserted in one smooth motion (Roche 2012).

Teflon cannula sets can also disconnect at or close to the site, providing lifestyle comfort and flexibility. The user unclips the tubing from the set base, leaving only the base and subcutaneous cannula in place, while removing the tubing and the pump. Some infusion sets may disconnect a few inches from the set base, leaving a short tubing “tail.” Some disconnect sets are self-sealing at the time of disconnection, whereas others require covers at the site as well as the end of the tubing.

A Teflon cannula set is more commonly used than a metal/steel infusion set. The latter is an option that you may recommend if your patient experiences problems with Teflon infusion set kinks or dislodgment, but this is not as common as it had been in past decades. Teflon cannula sets must be changed every 48 to 72 hours.

Some infusion sets are packaged with or without tubing, and some are packaged with extra “bases,” which allow changing of the metal/steel needle or Teflon cannula every few days, while using the tubing for several days longer, depending on the type of insulin used and other factors (see Sets with tubing). The latter type of packaging may be priced less than standard set base/tubing combination packages. Most infusion set combination packages are packaged 10 sets/box.

Discuss the features and benefits of each type of set—metal/steel and Teflon cannula—with your patient. Some patients use both types of sets and alternate depending on their activity.

Infusion set tubing comes in lengths ranging from 18 to 43 inches, depending on the manufacturer and the set. Manufacturers usually offer two or three tubing length options. Some manufacturers offer both clear and colored tubing. The colored tubing may help make it easier for the patient to view the insulin flow and detect air bubbles, which, if large (extending several inches), can account for non-delivery of insulin resulting in unexpected hyperglycemia.

Patients choose tubing length depending on their physical activity, sleeping habits, and clothing. For example, restless sleepers and people who wear their pump in their sock need longer tubing; those who wear the pump at their waist may prefer shorter tubing. Longer tubing may prevent dislodgment of the infusion set when using the bathroom (toilet) while the pump is attached to or in the pockets of pants that have been lowered to the floor. Any excess tubing can be easily tucked into the patient’s clothing and kept out of sight and there are companies that make devices that roll up tubing.

Additionally, some infusion sets allow tubing to be “directed,” i.e., the tubing position on the base can be changed, depending on the direction preferred by the user (right, left, upward, downward). Tying the tubing in knots does not impede the delivery of insulin, as the tubing is co-extruded (i.e., it has an inner small-diameter tube inside an outer tube). Advise the patient that if s/he would like to try different infusion sets or tubing lengths, their next order can include other available options offered by their pump manufacturer. The same is true for infusion set dressings, as some patients may experience an allergic skin reaction to the self-adhesive tape and may need to try another brand.

Customer Service and Other Practical Considerations

The pump manufacturer sales personnel should explain the start-to-finish process to both the potential pump user and to his or her healthcare professional or team. The pump patient must be confident that technical support and assistance are available 24 hours a day, 7 days a week. All pumps should have the company’s toll-free customer service number displayed on the back of the pump and/or remote device and corresponding communication devices (BG meter, CGM device).

Another consideration is the procedure for ordering supplies. The pump wearer should know what types of infusion sets, accessories, batteries, and specific pump items, such as cartridges/syringes, are needed. Most likely, replacement supplies are obtained by mail order from the pump manufacturer or pump supplier as contracted by the patient’s insurance company. Rarely are pump supplies available through a local pharmacy. Some manufacturers or supply companies offer to send the patient supplies routinely and automatically. What role does the manufacturer play in verifying insurance coverage for supplies?

On average, the price of an insulin pump ranges between $6,000 and $8,000, and most come with a 4-year warranty. Some pumps may cost less, as they may have disposable components, thus, less costly “hardware.” Medicare currently allows a pump to be replaced every 5 years (DHHS 2013). Supplies, including batteries, pump cartridges/syringes, infusion sets, skin prep items (and other items such as tape/dressing) can cost in excess of $1,500 each year. Help the patient understand the price of both the pump and supplies. Insurance coverage ranges from 50 to 100%, with most averaging about 80% coverage. Some insurance companies may provide coverage for the pump but not the supplies, or vice versa. Some patients have insurance policies with a high deductible or a low cap, such as $500/year, for durable medical equipment or medical supplies, which may be unfeasible for some patients.

The pump manufacturer should give a detailed cost estimate in writing to the patient and keep in touch with the patient throughout the insurance verification and pump and pump supplies ordering process. Usually, a pump manufacturer insurance specialist handles this process. The patient is required to sign an assignment of benefits document, allowing the pump manufacturer to determine the type and amount of insurance coverage provided. This can take one day to several weeks to process. An insulin pump is a prescription item, and the prescribing physician must provide the prescription and/or an order for an insulin pump and corresponding pump supplies to the patient and/or insurance company. Some insurance companies require a letter of medical necessity from the prescribing physician with additional documentation, which may include:

• Several weeks or months of SMBG records

• Recent A1C levels

• Reasons why an insulin pump may be necessary, e.g., erratic glucose pattern correction, preconception, pregnancy, diabetes complications requiring improvement in control, or lifestyle change

Almost every pump manufacturer has a standard “letter of medical necessity” checklist form. An individualized letter from the healthcare professional is rarely required except in the case of an appeal following a pump coverage rejection.

Some insurance providers may allow only certain contracted brands of insulin pumps. The patient should check with their insurance provider to confirm whether or not this is the case before selecting and ordering a pump. Patients who decide on an alternative brand usually need a letter or certificate of medical necessity from the prescribing physician explaining why another pump brand is preferred or required. Because this delays purchase and shipment of the pump, many clinicians have developed form letters to expedite the insurance approval and appeal process. Even if not initially covered, persistence can lead to a noncontract or nonformulary pump approval. Some patients pursue insulin pump insurance coverage for several brands of pumps and opt to settle for the pump that costs the least amount of money. Other patients are firm in their choice and are willing to provide whatever documentation the insurance company may require to approve a noncontract or nonformulary pump.

Patients can often request that the company ship the insulin pump directly to the home. However, overzealous and excited patients have been known to self-initiate pump therapy without formal training and have ended up in the emergency room in DKA or hypoglycemic shock. For this reason, some clinicians and diabetes educators request that the company ship a new pump to their site rather than to the patient’s home and insist that pump manufacturers provide scheduled formal pump training. Note that some physicians do not want to accept the liability of having a pump shipped to the office, as there is potential for the pump to be misplaced or lost, or to have it opened inadvertently, or even stolen. For this reason, some pump manufacturers prefer to ship the pump directly to the patient requiring a signature upon delivery. When a pump is shipped directly to the patient, advise the patient to check the shipping list for full contents. Direct the patient to review the pump tutorials and materials prior to office instruction. In either instance, reinforce to the patient to NOT initiate pump therapy without both formal training from the pump manufacturer and the presence of a healthcare professional (preferably the pump prescriber or designated HCP).

References

Department of Health and Human Services (DHHS) Centers for Medicare & Medicaid Services: National Coverage Determination (NCD) for Infusion PUMPs (280.14) http://www.cms.gov/medicare-coverage-database/details/nca-details.aspx?NCAId=40&NcaName=Insulin+Infusion+Pump&CoverageSelection=National&KeyWord=insulin+pump&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAABAAAAAA& Accessed 10 February 2013

Roche Insulin Delivery Systems, Inc.: ACCU-CHEK Guide to Infusion Site Management. Fishers, IN: 2012

Scheiner G: Matching patients to devices: diabetes products are not one-size-fits-all. Clinical Diabetes 30:126–129, 2012