es-pump-transition-los

name	es-pump-transition-los
description	Transition insulin pump to scheduled subcutaneous basal bolus insulin when anticipated hospital length of stay exceeds 1 to 2 days and pump expertise is unavailable. Triggers include: "Patient expected to stay >2 days, should we switch pump to scheduled insulin?"

Transition insulin pump to scheduled subcutaneous basal bolus insulin if anticipated length of stay >1-2 days

STEP 1 — Gather Information

• Anticipated hospital length of stay (LOS)
• Current insulin pump therapy status (type, basal rate, bolus settings)
• Availability of personnel with expertise in insulin pump therapy on the unit
• Patient ability to safely self‑manage pump settings (consciousness, cognition, manual dexterity)
• Availability of pump supplies (infusion sets, reservoirs, batteries) for the duration of stay
• Presence of contraindications to pump use (impaired consciousness, DKA, HHS, critical illness requiring vasopressors)

STEP 2 — Rule In / Rule Out

Is the anticipated LOS > 1 to 2 days?

• Yes → proceed to Step 3
• No → continue insulin pump therapy (if expertise available) or maintain current plan; no transition needed

STEP 3 — Classify or Stratify

Is there access to personnel with expertise in insulin pump therapy?

• Expertise available → continue insulin pump therapy (no transition)
• Expertise NOT available → proceed to Step 4 for transition

STEP 4 — Decide

Calculate basal insulin dose from pump’s 24‑hour basal rate (or use 0.2–0.4 U/kg/day if basal rate unknown) and administer as glargine U100 once daily or divided every 12 hours.
For prandial coverage: if patient uses carbohydrate counting at home, continue pump’s active basal profile for prandial/correction; otherwise use weight‑based fixed premeal doses 0.2–0.4 U/kg per meal (divided into 3 doses) with correctional insulin for glucose > target.
Hold prandial insulin if patient is NPO; continue correctional insulin every 4–6 hours.
After administering the calculated subcutaneous basal bolus regimen, discontinue the insulin pump.

Clinical Guardrails / Mimics / Pitfalls

• Do not transition if patient cannot safely self‑manage pump and expertise is present; abrupt pump removal risks DKA.
• Avoid transition in patients with impaired consciousness, DKA, HHS, or on vasopressor/inotropic support.
• Ensure basal insulin is given at least 2 hours before pump discontinuation to prevent hyperglycemia.
• Monitor glucose frequently (every 4–6 hours) after transition to detect hypo‑ or hyperglycemia.
• Do not use correctional insulin alone if persistent hyperglycemia (≥2 readings ≥180 mg/dL); add scheduled basal bolus as per step.

Concrete Clinical Example

A 58‑year‑old with type 1 diabetes on insulin pump (basal rate 0.75 U/hr, total daily dose 38 U) is admitted for pneumonia. The medical team anticipates a 3‑day stay and the ward lacks pump expertise. Basal dose = 0.75 U/hr × 24 h = 18 U → give glargine U100 18 U once daily. Prandial: weight 80 kg → 0.3 U/kg = 2.4 U per meal (round to 2 U) plus correctional lispro per glucose >150 mg/dL. After administering the first glargine dose and meal‑time lispro, the pump is discontinued.

Source: Management of Hyperglycemia in Hospitalized Adult Patients in Non-Critical Care Settings: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2022, DOI: 10.1210/clinem/dgac278

TODO: consider adding scripts/calc.py for the es-pump-transition-los calculator