Assess back-up plan for injected insulin if pump fails
STEP 1 — Gather Information
Collect current pump settings (basal rates, bolus insulin-to-carbohydrate ratio, correction factor), total daily dose, carbohydrate counting proficiency, ability to operate pump and troubleshoot alarms, knowledge of sick-day rules, and availability of emergency supplies (syringes/pens, long-acting and rapid-acting insulin, glucose tablets, glucagon).
STEP 2 — Rule In / Rule Out
Does the patient have a documented back-up plan for injected insulin if the pump fails?
- Yes → Proceed to assess plan adequacy.
- No → Identify need to create a back-up plan.
STEP 3 — Classify or Stratify
Classify the back-up plan as adequate if it includes:
- Correct basal insulin dose (e.g., long-acting analog equal to 24‑hour pump basal).
- Appropriate bolus dosing (insulin-to-carbohydrate ratio and correction factor).
- Carbohydrate counting ability.
- Knowledge of hypoglycemia treatment and DKA prevention.
- Access to injection supplies and emergency glucagon.
Otherwise, classify as inadequate.
STEP 4 — Decide
If adequate: Reinforce the plan, review annually or with device changes, and ensure supplies are current.
If inadequate: Collaborate with the patient to develop a written back‑up plan, provide education on basal‑bolus conversion, carbohydrate counting, sick‑day management, and prescribe necessary injection supplies.
Clinical Guardrails / Mimics / Pitfalls
Do not assume the patient knows how to convert pump basal to basal insulin without calculation. Avoid giving vague instructions; provide specific doses and ratios. Do not overlook hypoglycemia treatment or DKA prevention in the plan. Never rely solely on memory; ensure the plan is written and accessible.
Concrete Clinical Example
A 28‑year‑old using a Medtronic 670G pump with basal 1.0 U/hr (total 24 U/day), bolus ratio 1:10 g carb, correction factor 1 U per 50 mg/dL >150 mg/dL. If pump fails, the back‑up plan is insulin glargine 24 U subcut daily at bedtime, insulin aspart 1 U per 10 g carbs plus correction per glucose, with glucose checks every 2‑4 hrs, ketone monitoring if glucose >250 mg/dL, and glucagon kit available.
Source: Diabetes Technology—Continuous Subcutaneous Insulin Infusion Therapy and Continuous Glucose Monitoring in Adults: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2016, DOI:10.1210/jc.2016-2534