Documentation of Continuous Subcutaneous Insulin Infusion (CSII) Use in the Emergency Department (ED)

Abstract

The Institute for Safe Medication Practices recommends patients on CSII who present to the hospital (inpatient or the ED), should have CSII use and settings verified within 12 hours. Without CSII orders or scheduled glucose checks in the ED, adverse glycemic excursions from insulin pump misadventures can occur, increasing risk of DKA or severe hypoglycemia. At University of California, San Francisco, (UCSF) 25% of admitted patients enter via the ED with an average door-to-admission of > 12 hours. We have mandatory insulin pump orders for inpatients. To determine the timing of CSII orders, documentation and glucose levels, we performed a retrospective review of patients admitted from the ED who remained on CSII, from June 2012 to August 2016. 32 patients (age 54.3 ± 14.6 years) were admitted to the hospital from the ED who were continued on CSII. We were unable to capture data on ED patients not admitted or who had their CSII discontinued. 37.5% did not have CSII orders written within 12 hours of presentation to the ED. The average time to insulin pump order was 13.3 hours. 43% presented to the ED between1900-0700. The mean time to first glucose was 1.27 hours ± 1.47, and 15.6% had no glucose check within the first 2 hours. <50% had CSII integrity documented (insulin reservoir, site intact, battery capacity) in the first 24 hours. Glycemic control was assessed by 6-hour periods. For these 4 periods: Glucose 80-180 mg/dl (13/32; 12/32; 15/32; 9/32); >180 mg/dl (18/32; 11/32; 12/32; 12/32); <80 mg/dl (0/32; 2/32; 2/32; 2/32); no glucose (0/32; 7/32; 3/32; 9/32). Continuous glucose monitor readings are not part of the patient’s medical record as not approved for clinical decision making. We found few patients had CSII orders or documentation nor appropriate glucose monitoring in the initial 12 hours after presentation to the ED. We anticipate new ED policies, procedures, and RN protocols, with use of new ED pump order sets and early patient involvement, will improve guideline compliance and patient care. Disclosure R.J. Rushakoff: None. J. Zook: None. H.W. Macmaster: None.