Safety issues: Use of continuous subcutaneous insulin infusion (CSII) pumps in hospitalized patients

Hospital Pharmacy

Volumn 41, Issue 10, 2006, Pages 956-969

  Dalton, Mazie F ^a   Klipfel, Laurie ^a   Carmichael, Kim ^b  

^a Forest Park Hospital   (United States)

^b WASHINGTON UNIVERSITY SCHOOL OF MEDICINE   (United States)

Author keywords

Clinical protocols; Diabetes mellitus; Hospital management; Insulin infusion systems

Indexed keywords

INSULIN;

CAREGIVER; DIABETES MELLITUS; DRUG SAFETY; HOSPITAL ADMISSION; HOSPITAL MANAGEMENT; HUMAN; INSULIN INFUSION; INSULIN PUMP; INSULIN TREATMENT; MEDICAL EDUCATION; MEDICAL PERSONNEL; MEDICATION ERROR; POLICY; PRACTICE GUIDELINE; REVIEW; RISK FACTOR;

EID: 33750619220     PISSN: 00185787     EISSN: None     Source Type: Journal    
DOI: 10.1310/hpj4110-956     Document Type: Review

References (50)

1. Centers for Disease Control and Prevention. National diabetes surveillance system; prevalence of diabetes number (in millions) of persons with diagnosed diabetes, United States, 1980-2004. Available at: http://www.cdc.gov/diabetes/statistics/prev/national/figpersons.htm. Accessed February 2, 2006.
2. Centers for Disease Control and Prevention. National diabetes fact sheet; total prevalence of diabetes in the United States, all ages, 2005. Available at: http://www.cdc.gov/diabetes/pubs/estimates05.htm#prev. Accessed February 2, 2006.
3. National diabetes surveillance system; hospitalizations for diabetes as any-listed diagnosis. Number (in thousands) of hospital discharges with diabetes as any-listed diagnosis, United States, 1980-2003. http://www.cdc.gov/diabetes/ statistics/dmany/fig1.htm. Accessed February 2, 2006.
4. Levetan CS, Passaro M, Jablonski, Kass M, Ratner RE. Unrecognized diabetes among hospitalized patients. Diabetes Care. 1998;21:246-249.
5. Zerr KJ, Furnary AP, Grunkemeier GL, Bookin S, Kanhere V, Starr A. Glucose control lowers the risks of wound infection in diabetics after open heart operations. Ann Thorac Surg. 1997;63:356-361.
6. Furnary AP, Zerr KJ, Grunkemeier GL, Heller CA. Hyperglycemia: a predictor of mortality following CABG in diabetics. Circulation. 1999;100(suppl):1591.
7. Bolk J, van der Ploeg T, Cornel JH, Arnold AE, Sepers J, Umans VA. Impaired glucose metabolism predicts mortality after a myocardial infarction. Int J Cardiol 2001;79:207-214.
8. Capes SE, Hunt D, Malmberg K, Gerstein HC. Stress hyperglycaemia and increased risk of death after myocardial infarction in patients with and without diabetes: a systematic overview. Lancet. 2000;355;773-778.
9. Kosiborod M, Rathmore SS, Inzucchi SE. Admission glucose and mortality in elderly patients hospitalized with acute myocardial infarction: implications for patients with and without recognized diabetes. Circulation. 2005;111:3078-3086.
10. Krinsley J. Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients. Mayo Clin Proc. 2003;78:1471-1418.
11. Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001;345:1359-1367.
12. Cheung NW, Napier B, Zaccaria C, Fletcher JP. Hyperglycemia is associated with adverse outcomes in patients receiving total patenteral nutrition. Diabetes Care. 2005;28:2367-2371.
13. Capes SE, Hunt D, Malmberg K, Pathak P, Gerstein HC. Stress hyperglycemia and prognosis of stroke in non-diabetic and diabetic patients: a systematic overview. Stroke. 2001;32:2426-2432.
14. Williams LS, Rotich J, Fineberg N, et al. Effects of admission hyperglycemia on mortality and cost in acute ischemic stroke. Neurology. 2002;59:67-71.
15. Parsons MW, Barber PA, Desmond PM, et al. Acute hyperglycemia adversely affects stroke outcome: a magnetic resonance imaging and spectroscopy study. Ann Neurol. 2002;52:20-28.
16. Pomposelli JJ, Baxter JK 3rd, Babineau TJ, et al. Early postoperative glucose control predicts nosocomial infection rate in diabetic patients. JPEN J Parenter Enter Nutr. 1998;22:77-81.
17. Golden SH, Peart-Vigilance C, Kao W, Brancati FL. Peri-operative glycemic control and the risk of infectious complications in a cohort of adults with diabetes. Diabetes Care. 1999;22:1408-1414.
18. Furnary AP, Gao G, Grunkemeier GL, et al. Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2003;125:1007-1021.
19. Malmberg K. Prospective randomized study of intensive insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus. BMJ. 1997;314:1512-1515.
20. Malmberg K, Norhammar A, Wedel H, Ryden L. Glycometabolic state at admission: important risk marker of mortality in conventionally treated patients with diabetes mellitus and acute myocardial infarction: long-term results from the Diabetes and Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) study. Circulation. 1999;99:2626-2632.
21. Garber AJ, Moghissi ES, Bransom ED, et al. American College of Endocrinology position statement on inpatient diabetes and metabolic control. Endocrine Pract. 2004;10:77-82.
22. Clement S, Braithwaite SS, Magee MF, et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27:553-591.
23. Pickup JC, Keen H, Parsons JA, Alberti KG. Continuous subcutaneous insulin infusion: an approach to achieving normoglycaemia. BMJ. 1978;1:204-207.
24. Tamboriane WJ, Sherwin RS, Genel M, Felig P. Reduction to normal of plasma glucose in juvenile diabetes by subcutanous administration of insulin with a portable infusion pump. N Engl J Med. 1978;300:573-578.
25. Pickup JC, Keen H, Viberti GC, et al. Continuous subcutaneous insulin infusion in the treatment of diabetes mellitus. Diabetes Care. 1980;3:290-300.
26. Pickup J, Keen H, Continuous subcutaneous insulin infusion at 25 years: evidence base for the expanding use of insulin pump therapy in type 1 diabetes. Diabetes Care. 2002;25:593-598.
27. Torrance T, Franklin V, Greene S. Insulin pumps. Arch Dis Child. 2003;88:949-953.
28. Diabetes Control and Complications Trial Research Group DCCT. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Eng J Med. 1993;329:977-986.
29. Quinn C. Infusion devices: understanding the patient perspective to avoid errors. Prof Nurse. 2003;19:79-83.
30. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients - results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324:377-384.
31. The United States Pharmacopeial Convention Inc. Top 50 drug products associated with medication errors-July 2002-June 2003 Copyright 2005. Available at: http://www.usp.org/patientSafety/resources/top50DrugErrors.html. Accessed February 2, 2006.
32. Santell J, Cousins D. Insulin errors a common problem. U.S. Pharmacist. 2003;28. Available at: http://www. uspharmacist.com/index.asp?show= article&page=8_1169.htm. Accessed February 2, 2006.
33. Anonymous. 33% of fatal med errors involve insulin therapy. Healthcare Benchmarks Qual Improv. 2005;12:21-22.
34. Cohen M. Medication errors. Washington, D.C. Institute for Safe Medication Practices, American Pharmaceutical Association; 1999.
35. Grissinger M, Lease M. Misadventures in insulin therapy: are you at risk? J Natl Med Assoc. 2003;95(2 suppl 1):1S-16S.
36. Hellman R. A systems approach to reducing errors in insulin therapy in the inpatient setting. Endocrine Practice. 2004;10 (suppl 2):100-108.
37. Rozich JD, Howard RJ, Justeson JM, et al. Standardization as a mechanism to improve safety in health care. Jt Comm J Qual Safety. 2004;30:5-14.
38. ASHP Guidelines on preventing medication errors in hospitals. Am J Health-Syst Pharm. 2000;57:1531-1532.
39. Rafoth RJ. Standardizing sliding scale insulin orders. Am J Med Qual. 2002;17(5):175-8.
40. Anonymous. 'High-alert' medications and patient safety. Int J Qual Health Care. 2001;13:339-340.
41. Joint Commission on Accreditation of Healthcare Organizations. FAQ about Patient Safety Goals 2005 and 2006 "Do Not Use" List. Available at: http://www.jcipatientsafety.org/show.asp ?durki=12293&site=164&return= 9335. Accessed February 2, 2006.
42. ISMP Medication Safety Alert. ISMP List of error-prone abbreviations, symbols, and dose designations. C2003 ISMP. Available at: http://www.usp.org/ pdf/EN/patientSafety/ismpAbbreviations.pdf. Accessed February 2, 2006.
43. ISMP Medication Safety Alert. Insulin errors - abbreviations will get U in trouble. 9/13/1997. Available at: http://www.ismp.org/MSAarticles/Insuli n.html. Accessed February 2, 2006.
44. Lee SW, Im, R, Magbual R. Current perspectives on the use of continuous subcutaneous insulin infusion in the acute care setting and overview of therapy. Crit Care Nurs Q. 2004;27:172-184.
45. Fain JA. Pump up your knowledge of insulin pumps. Nursing. 2003;33:51-53.
46. Ahmed Z, Lockhart CH, Weiner M, Klingensith G. Advances in diabetic management: implications for anesthesia. Anesth Analg. 2005;100:666-669.
47. Hess-Fischl A. Practical management of patients with diabetes in critical care: from a diabetes educator's perspective. Crit Care Nurs Q. 2004;27:189-200.
48. Savinetti-Rose B, Bolmer L. Understanding continuous subcutaneous insulin infusion therapy. Am J Nurs. 1997;97:42-48.
49. Lenhard MJ, Reeves GD. Continuous subcutaneous insulin infusion: a comprehensive review of insulin pump therapy. Arch Intern Med. 2001;161:2293-2300.
50. Cook CB, Boyle ME, NS Cisar, et al. Use of continuous subcutaneous insulin infusion (insulin pump) therapy in the hospital setting: proposed guidelines and outcome measures. Diabetes Care. 2005;31:849-857.