6NU521 Diabetes: Insulin Pump Therapy - A Contemporary Approach

This report provides a critical discussion on the role of insulin pumps in the management of type 1 diabetes, reviewing current evidence-based principles for effective utilization. It highlights the significance of insulin pump therapy in mimicking physiological insulin secretion, offering lifestyle flexibility, and improving quality of life for diabetic patients. The report also addresses potential risks and challenges associated with insulin pump use, such as pump failure, user errors, and adverse events, emphasizing the importance of patient education and standardized reporting of adverse events. By considering evidence-based practices and contextual factors, the report suggests strategies to support clients with type 1 diabetes in safely and effectively using insulin pumps, ultimately aiming to enhance their well-being and diabetes management outcomes. Desklib offers a wealth of similar solved assignments and study resources for students.

Running head: DIABETES
Diabetes
Name of the student:
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CW1- A critical discussion on the role of insulin pumps in the management of diabetes
Introduction:
Diabetes is a metabolic disorder characterized by presence of symptoms like
hyperglycemia, insulin resistance and relative insulin deficiency (Zaccardi et al. 2016). Although
type 2 diabetes is most commonly diagnosed in people, however management of type 1 diabetes
is also challenging because of the need to maintain insulin deficiency. Another issue is that type
1 diabetes can be seen at any age. The diagnosis of the condition presents additional challenges
for elderly people because the process of ageing may significantly influence diabetes
management. For example, adults with type 1 diabetes (T1D) are most likely to suffer from
malnutrition because of impaired sense of taste and self-management becomes difficult for them
because of impaired vision (Kilvert and Fox 2015). In contrast, the incidence of T1D in children
below 6 years is rising and inability to control T1D in children contributes to increase in parental
stress (Streisand and Monaghan 2014). Insulin therapy is the cornerstone for T1D management
and the main purpose of this report is to critically discuss about the role of insulin pumps in the
management of T1D and review current evidence based principles to effectively use insulin
pumps for the treatment of T1D. This is based on the case study mentioned in appendix.
Critical discussion on the role of insulin pumps in diabetes treatment:
Significance of insulin pump therapy
Insulin pump therapy is one of the new methods for delivering insulin to people with
T1D. Although insulin pumps are available since the 1980s, modern pumps have come up that
have eliminated barriers related to pump failure. Insulin pump is mainly a small and portable
insulin delivery device which delivers short acting insulin continuously via subcutaneous site.

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Fast acting insulin analogue is the most recommended insulin pumps and the main advantage of
this therapy is that it mimics physiological insulin secretion by making insulin available 24 hours
a day. Another advantage of insulin pump is that it gives diabetic patient the chance to lead a
more flexible lifestyle instead of restricting their food cravings (Shulman et al. 2016). Maahs,
Horton and Chase (2010) suggested that insulin pump use in children is associated with
enhanced blood sugar control, easy adjustment of insulin dose with travel and better control of
port-meal blood sugar values. Despite the advantage of insulin pumps as a rapid acting insulin
analogue, the success of the technology is dependent on skills and knowledge of users too. Those
using insulin pumps need to frequently monitor blood glucose level and pay attention to
mechanical and injection site issues too (Shulman et al. 2016). Hence, reviewing the evidence
based for mitigating these form of challenges for pump users is important.
The importance of insulin pump on diabetes management is also understood from its
impact on quality of life parameters. Ghazanfar et al. (2016) revealed that the use of insulin
pump significantly improves quality of life of diabetic patients. The study used case-control
study approach to investigate about the impact of insulin pumps on patient using insulin pump
and the control group not using the pump. Patients who are diagnosed with diabetes often suffer
from poor self-esteem because of diet restrictions and poor physical health (Luyckx et al. 2016).
However, the study revealed increase in self-esteem, decrease in stress and better mood for
patients using insulin pumps because of flexibility in meal eating time. The use of insulin pumps
increased meal eating timing. Other options for patients included use of multiple insulin
injections and such patients need to follow a strict schedule for their meal time. This has impact
on social activity of patients too. However, the use of insulin pumps has been associated with
greater flexibility in life for diabetic patient, with regard to meal time flexibility and socialization

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(Ghazanfar et al. 2016). Hence, insulin pump can act as new source of hope for people who are
troubled by the diagnosis of diabetes and its associated changes in their social life.
Evidence for benefits and risk associated with insulin pump use
Based on the case study, considering the potential of insulin pump in the management of
patients with diabetes is important as it will help to understand positive benefits of the
technology and any potential issues related to its use for certain group too. Although insulin can
be delivered to T1D patients by multiple means, however there are many research evidences
which show why insulin pump is superior to other insulin delivery methods. A qualitative
research by Alsairafi et al. (2018) investigating about the patient’s experience related to insulin
pump use revealed several advantages of insulin pumps in relation to glycaemic control, quality
of life and adherence to dosage. Cross-sectional semi-structured interview method was used to
explore patient’s view about the use of insulin pumps. The review of participant’s response
revealed that use of insulin pump was associated with improved blood glucose level and there
were fewer hyoglycaemic episodes for patients on insulin pumps compared to MDI (multiple
daily injections). Another most positive outcome of insulin pump use was that it was associated
with improved adherence to dose administration. This evidence suggests the advantage and
potential of insulin pumps for patients with diabetes. Such positive outcomes have been possible
because of technological advancements of insulin pumps over other delivery methods. Automatic
dose calculation is the feature in the device that has reduced management challenges for people
with diabetes.
Another research by Grose et al. (2018) used qualitative approach to explore experience
of people living with T1D and using an insulin pump. The main difference in life for participant

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was that insulin pump has given them better flexibility. However, there were also certain patient
groups who reported difficulty and newer restrictions on their lifestyle because of insulin pump
therapy. Some participants reported difficulties with concealing the pump when wearing certain
clothing and others found the device to be obtrusive while doing exercise. Despite this, the
broader message was that participants expressed improved sense of well-being after initiating the
CSII therapy.
Consideration of evidence based principles to resolve issue related to insulin pump use
To consider application of the evidence to initiate insulin pump use in the case study,
there is a need to consider evidence based principles before it can be applied in the case study
situation. Evidence based practice is a problem-based approach where clinical decision making is
informed by research evidence. In case of any clinical encounter which is associated confusion,
health care practitioners should take the approach to identify best research evidence and take into
account patient’s beliefs and other circumstances that could affect the application of research
evidence (LoBiondo-Wood and Haber 2017). Hence, to effectively use insulin pumps to achieve
positive outcome for patients with T1D, there is a need to review challenges both for patient and
staffs and identify possible solutions to eliminate these barriers.
The study by Grose et al. (2018) revealed that despite advantage of insulin pump therapy,
there are many flaws that limit use of insulin pumps for all types of patient. However, the
evidence is not considered reliable because of selection bias. The study was done only with T1D
patients who were pump users. There is a need to evaluate studies where staffs and other patient
groups have also reported the same difficulty. This approach would help to resolve the barriers
identified and find appropriate solution to promote use of insulin pumps for all T1D patients

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without any difficulty. The critical appraisal of possible risk associated with insulin pumps and
the review of safety standards would help to understand the application of the technology in the
case study. The research study by Heinemann et al.
(2015) is significant in this regard as it focused on investigating about possible errors during the
use of insulin pumps. The study indicates that by the use of insulin pumps, the users are most
likely to be exposed to fatal hazards because of pump failure, insulin infusion set blockage, user
related errors, infusion site issues and insulin instability issues. To appropriately respond to
adverse events reported after the use of insulin pumps, there is a need to take more standardized
and transparent approach to identify and report adverse events. This evidence suggest the need
for educating clients regarding safe use of insulin pumps too before it can be readily used by
clients in their daily life (Heinemann et al. 2015).
Possible adverse events caused due to use of insulin pumps among diabetic patients
Despite availability of enough evidence to prove the benefits of insulin pumps for
treatment of diabetes, presence of certain challenges in the use of insulin pump also suggest the
need for evidence based guidelines to achieve optimal outcome for patient. Before fully
implementing the insulin pump therapy for particular patient, the first step that is needed as per
evidence based practice principle is to critically appraise evidence related to the adverse events
related to the use of pumps. This would help to identify adjustments needed to achieve full
benefits of the technology for target patient or patient group. A literature review by Ross et al.
(2015) gave details on insulin pumps related adverse events in adults and children. The study
revealed that that at least 40-45% of pediatric and adolescent patients using modern generation
insulin pumps experience one or more adverse events per year. The most common cause of
errors included pump failure and infusion set failures. The number of pump replacement is also

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an indication of the significance of the pump malfunction issues. Other forms of error include
occlusion, catheter associated errors, cutaneous complications, infection. Some of the acute
metabolic adverse events include diabetic ketoacidosis and hypoglycemia. This form of thorough
understanding about adverse events in the clinical setting might help to conduct appropriate pre
and post marketing surveillance for adverse events. The review of adverse events also suggests
that ongoing education and support for patient is paramount to ensure safe use of device. This
step would help to critically review patient factor as well as other factors that might affect
utilization of the technology.
The significance of the evidence by Ross et al. (2016) is that it focused not only on
evaluation of potential adverse event only in one pediatric center, but also on insulin pump
associated adverse events in New Zealand adults and children with T1D. The examination of
participant’s response to pump-related issues revealed hypoglycemia and pump malfunction was
the reason behind various adverse events. Pump malfunction mainly occurred because of
physical damage, battery related issue, insulin leakage, missing hardware parts and water
damage. Participants in the study mainly sought assistance from the pump manufacturer’s
customer care line and the hospital diabetes service. The strength of the study is that
heterogeneous population group has been analyzed to understand types of adverse events
occurring due to insulin pump use. Furthermore, multi-center study has enhanced the credibility
of the research findings. The study gives the implication that like all technology, insulin pumps
are also infallible and patient education plays a vital role in promoting successful and safe use of
pumps. Hence, the experience of the client in the case study can be enhanced if education and
training related to pump use is given in an effective manner.

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Providing support to client with T1D related to safe insulin pump use
As per the evidence based practice principle, best available evidence should be applied
considering the contextual factor of patients. In the context of case study, patient can be
supported to effectively use the insulin pump by the utilization of best evidence related to safety
of insulin pumps. The success of initiating insulin pump therapy would depend on educating the
client regarding site preparation, basal bolus insulin therapy, glucagon administration and
prevention and treatment of hypoglycemia. Certified insulin pump users like registered nurse,
dietitians and pharmacists can engage in providing diabetes education. The initial education
session can focus on providing education related to basics of pump operation and then it can
proceed with in-depth education on management of infusion site issues and additional strategies
related to pump success (Reece and Williams 2014).
As per the evidence based practice principles, the successful integration of evidence
based practice is dependent on identifying areas of concern, putting research into action and
sharing the knowledge (Straus et al. 2018). The review of adverse events related to insulin pump
use suggests the need to put research into action by identifying possible solution to reduce
adverse events. The review of studies by Ross et al. (2016) and Ross et al. (2015) gives the
implication to use education as a means to pass on and share new knowledge with patients. This
would help to address clinical problem and implement appropriate quality improvement
initiatives too. The above discussion suggested possible steps that can be taken to provide
education to patients with T1D regarding safe insulin pump use. However, another thing that
needs to be considered to ensure patients are confident in using insulin pumps includes
identifying personal barriers faced by patients and developing solutions to reduce those barriers.

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Tanenbaum et al. (2017) investigated about the barrier to uptake of diabetes device use in
adults with T1D. The significance of research in this area is that it can pave way for modifying
the design of intervention to increase the uptake of the device. Tanenbaum et al. (2017)
categorized barriers into modifiable and non-modifiable factors. Although non-modifiable
factors like cost and health insurance are addressed by policy makers, other factors like patient’s
perception or attitude towards technology use can be modified by health care professionals like
nurse and patient. The investigation regarding the reasons for discontinuing device use revealed
that cost of device as the most common barrier followed by hassle of wearing devices and not
liking the device on one’s body. Another common link was barrier to use device was higher in
patients who were younger. Hence, this evidence can be put into action by considering actions
that can be taken to eliminate physical barriers to increase device uptake in relation to the case
study.
Many innovative approaches have been identified to overcome barrier related to device
use for the case study. Although physical barrier related to insulin pump use cannot be addressed
by considering design size, however psychosocial intervention can be beneficial in addressing
user’s ability to cope with physical barriers. For example, they can be taught problem solving
technique to manage physical barriers associated with device use. Patients can be educated
regarding the significance of the technology in response to other devices and they may be
motivated to use the device by showing how far insulin pump use can enhance the quality of life.
This would lead to change in attitude towards use of device. Furthermore, adherence to device
use can be achieved by better communication between device experts and patient so that ongoing
support can be used to provide ongoing support for users and reduce the likelihood of device
discontinuation (Alsairafi et al. 2018).

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Conclusion:
To conclude, the critical discussion on the role of insulin pump for management of T1D
indicates insulin pumps as an effective device to resolve the issue of hyperglycemia and
managing insulin level for T1D patient. Another advantage of this device is that it provides
lifestyle flexibility to users and improves quality of life of patient. However as certain barriers to
the use of insulin pump has been identify, the report used the evidence based practice principles
to identify best evidence, interpret them and find possible solutions to address the clinical issue
in the case study.

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CW2- Short answers
1. Three symptoms of diabetes include frequent urination, feeling of thirst and hunger and
extreme fatigue.
2. 3 social determinants influencing self-management of type II diabetes includes education
level, employment and poverty.
3. Primary prevention in diabetes involves the prevention of diabetes by reducing or
eliminating risk of diabetes among target population. It is concerned with interventions
that prevent the onset of diabetes in people. The secondary prevention of diabetes
involves reducing the impact or severity of the condition in people already diagnosed
with diabetes.
4. The first resource that can be used for management of diabetes includes the NICE
guidelines for management of type 2 diabetes in adults (NICE 2017). The advantage of
using NICE guideline is that it is a reliable source that provides structured education on
individualized care and managing complications in patient. Another resource that can be
utilized includes the evidence based nutrition guidelines for prevention of diabetes
developed by Diabetes UK (Diabetes UK. 2018). The significance of this resource is that
each informed is backed up by evidence based evidences too.
5. a) Signs and symptoms of gestational diabetes: Frequent urination, unusual thirst and
fatigue
b) Risk factors: Advancing age, obesity, hypertension and excessive central body fat
deposition (Pons et al. 2015).

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c) Good management practice: Implementing self-blood glucose monitoring education and
medical nutrition therapy is considered as effective management practice for gestations
diabetes (Meloncelli et al. 2018).
6. Secondary diabetes may be caused by cystic fibrosis, hormonal syndrome that interferes
with insulin secretion and hormonal syndrome that lead to peripheral insulin resistance.
7. a. After eating a food, blood sugar level increases. Specialized cells respond to this signal
by releasing insulin hormone. This results in decrease in blood sugar level leading to a
negative feedback mechanism.
b. Glucagon plays a role in initiating negative feedback mechanism in low blood sugar and
increasing blood sugar level. During sleep or between meals, blood glucose levels are low
and glucagon is released to increase endogenous blood glucose level (Röder et al. 2016).
8. Pancreas is mainly involved in maintaining the blood glucose level and the primary
hormones involved in blood glucose regulation includes the insulin, glucagon, gastrin and
somatostatin hormone. Pancreas plays a role in producing hormones and maintaining blood
sugar balance (Röder et al. 2016).
9. Difference between prevalence and incidence is that incidence is the rate of newly
diagnosed cases of disease within a specific time period, whereas prevalence is the actual
number of cases living with the disease during a period of time.
10. The term mortality is used in epidemiology mainly to indicate number of deaths
occurring due to a disease, whereas morbidity refers to the state of being ill with several
health issues.