Transcript File - Kathy Bowers Nurse Educator Portfolio

Glycemic Control:
The Ongoing Quest
Kathy Bowers
Ferris State University
Inpatient RN Focus
Fall 2013
Continuing Nursing Education Credit
Criteria/Disclaimers
• To achieve 2 nursing contact hours, attendee must:
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Sign in
Complete pre-test
Attend entire session
Complete post-test and evaluation
• All planners and presenters deny conflict of interest
McLaren Northern Michigan (OH-307, 6-1-2016) is an approved provider of
continuing nursing education by the Ohio Nurses Association (OBN-001-91),
an accredited approver by the American Nurses Credentialing Center's
Commission on Accreditation.
Objectives
At end of offering, participant will be able to:
• Demonstrates understanding of hypoglycemia protocol and
identifies measures to prevent further hypoglycemic events.
• Demonstrates understanding of pharmacology of insulin’s
and use of basal, prandial and correction dose insulin
indications.
• Demonstrates knowledge of blood sugar targets in critical
and non critical care units.
• Demonstrates understanding of carbohydrate counting and
calculation of insulin to carbohydrate ratios.
• Demonstrates understanding of continuous insulin infusion
protocol and indications for use.
Module 1:
Diabetes 101
Classifications
• Type 1 diabetes
– β-cell destruction
• Type 2 diabetes
– Progressive insulin secretory defect
• Other specific types of diabetes
– Genetic defects in β-cell function, insulin action
– Diseases of the exocrine pancreas
– Drug- or chemical-induced
• Gestational diabetes mellitus (GDM)
ADA. I. Classification and Diagnosis. Diabetes Care 2013;36(suppl 1):S11.
Pathophysiology of T2DM
Inherited/acquired factors
Insulin deficiency
Acquired factors (obesity)
Insulin resistance
 FFA
Gluco-lipotoxicity
 Glucose
uptake  Production of glucose in
the liver
Hyperglycemia
T2DM
FFA = free fatty acid.
Bergenstal R, et al. Endocrinology. Philadelphia, PA: WB Saunders Co; 2001:821-835. DeFronzo RA. Diabetes.
1988;37(6):667-687. Poitout V, et al. Endocrinology. 2002;143(2):339-342.
Multiple Contributors
Decreased
incretin effect
Decreased insulin
secretion
Increased
lipolysis
Islet–A cell
ETIOLOGY OF T2DM
Impaired Insulin
Secretion
Increased Lipolysis
Hyperglycemia
Increased
HGP
Decreased Glucose
Uptake
DEFN75-3/99
Hyperglycemia
Increased
glucagon
secretion
Increased
glucose reabsorption
Increased
HGP
Neurotransmitter
dysfunction
HGP = hepatic glucose production.
Defronzo RA. Diabetes. 2009;58(4):773-795.
Decreased
glucose uptake
Primary Types of Diabetes
Type 1 DM
• Life-long
– Develops at any age
• Onset sudden or gradual
• Daily insulin dependent
All patients with known
T1DM should be given
exogenous insulin
DO NOT hold basal insulin
in these patients
Type 2 DM
• Occurs at any age
o Onset in adolescents
becoming more
common
• Usually due to insulin
resistance with insulin
deficiency, and/or insulin
secretory defect with
insulin resistance
• Need for insulin variable
• May worsen over time
CPM Clinical Practice Guidelines: Type 1 Diabetes-Adult, Type 2 Diabetes-Adult. Fall 2010
Complications
• Leading cause of kidney failure, nontraumatic lowerlimb amputation, new cases of blindness among adults
• Major cause of heart disease and stroke
• Seventh leading cause of death
National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at:
http://diabetes.niddk.nih.gov/dm/pubs/statistics/
Diabetes Frequency
US Average
• 8.3% population (25.8 million people) estimated to have
diabetes, including 18.8 million diagnosed and 7 million
undiagnosed
– For every 2 known people with diabetes, there is an
unknown
– Type 1: 5-10% of diagnosis
– Type 2: 90-95%
National Diabetes Information Clearinghouse. National Diabetes Statistics, 2011. Available at:
http://diabetes.niddk.nih.gov/dm/pubs/statistics/
Diabetes Frequency
MNM Population
• CDC reports Emmet County DM rate 8.1-9.4% in 2008
• Charlevoix, Cheboygan 9.5-11.1
• Mackinac > 11.1
• 20-30 (20-30%) Patients on Insulin on any given day
www.cdc.gov
Screening on Admission
DM Risk Factors
• Age >45
• 18-45 with additional risk factor:
Sedentary
Overweight/obese
Family history of DM
High-risk ethnicity (Pacific Islander, Native
American, African American, Latino, Asian American)
– Female with history of gestational diabetes or
delivery of baby over 9 lbs
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–
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Diagnosis
A1C ≥6.5%
OR
Fasting plasma glucose (FPG)
≥126 mg/dL (7.0 mmol/L)
OR
2 random plasma glucose
≥200 mg/dL (11.1 mmol/L)
ADA. I. Classification and Diagnosis. Diabetes Care 2013;36(suppl 1):S13; Table 2.
Screening on Admission
ID the Unknown: Random BG
• Report >200
• A1c next step
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3 month avg. BG control
Normal <5.7%
Pre Diabetes 5.7-6.5%
Diabetes Target <7%
A1c (%)
Average BG (mg/dL)
6
126
7
154
8
183
9
212
10
240
11
269
12
298
Pre Diabetes
FPG 100–125 mg/dL
OR
A1C 5.7–6.4%
*Risk is continuous, extending below the lower limit of a range and becoming disproportionately greater
at higher ends of the range.
Recommendations
Prevention/Delay of Type 2 Diabetes
• Patients with FBG 100–125 mg/dL or A1C 5.7–6.4% to
ongoing support program
— Targeting weight loss of 7% of body weight
— At least 150 min/week moderate physical activity
— Follow-up counseling
ADA. IV. Prevention/Delay of Type 2 Diabetes. Diabetes Care 2013;36(suppl 1):S16.
In-Hospital Hyperglycemia
Risks
• Prevention in critical and non-critical care settings can
reduce mortality, morbidity and costs associated with
prolonged length of stay.
• Independent factor for poor clinical outcomes:
– Infection
o 2 hours over 180mg/dL=5 times risk
o Sepsis
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–
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Delayed wound healing
Skin breakdown
DKA
Coma
Death
In-Hospital Hyperglycemia
Causes (Even unrelated to Diabetes)
• Most Common
– Insulin deficiency
– Inappropriate insulin therapy
– Infection
• Other
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Surgery
Illness
Stress
Medication induced (e.g. steroids)
CPM Clinical Practice Guidelines: Type 1 Diabetes-Adult, Type 2 Diabetes-Adult. Fall 2010
BG Targets
Non Critical Care
• AC 80-140 mg/dL
• PC blood glucose targets <180 mg/dL
• Random blood glucose targets <180 mg/dL
Critical Care
• 110-140 mg/dL for most patients
Targets
200 mg/dL
SCIP threshold
180
Upper ICU/Non-ICU
Random Target
Upper Non-ICU Prandial
Target
Lower ICU Target
Lower Non-ICU Prandial
Target
Hypoglycemia
Severe Hypoglycemia
140
110
80
70
40
In-Hospital Hyperglycemia
Treatment may differ from home
• Critical Care: IV insulin infusion is preferred
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–
–
Rapid onset
Short duration of action
Predictable glucose lowering effect
Low risk of prolonged hypoglycemia
• Non Critical Care: Subcutaneous insulin is preferred—
even if patient is not on insulin at home.
– Adjustable
– Predictable response
– Does not necessarily mean patient will be
discharged on insulin
1. Schmeltz LR et al. EndocrPract.2006;12:641-650. 2. Umpierrez GE. J ClinEndocrinol . 2002; 87:978-982. 3. Capes SE. et al.
Stroke.2001;32:2426-2432. 4. Furnary AP et al. Am J Cardiol.2006;98:557-564. 5. Clement S et al. Diabetes Care.2004;27:553-591.
6.Moghissi ES et al. Diabetes Care. 2009;32:1119-1131. Metab
Module 2:
Menus, Carbohydrates
and
Carb Counting
Medical Nutritional Therapy: Carbs
Why Count Carbohydrates?
• Carbohydrates include food composed of starches, sugar, and/or fiber.
They are the most common form of energy found in food. Most
carbohydrates break down into glucose.
• Proteins and fats make up the other two sources of energy and do not
break down into glucose.
Carbohydrates:
Protein:
Fats:
Fruits and Vegetables
Meats - beef, pork,
poultry, lamb, fish,
shellfish
Oils
Grain Products, like breads,
cereals, crackers, rice, cereal,
pasta
Dried or Canned Beans, Peas,
and Lentils
Dairy Products, mainly Milk and
Yogurt
Sugar and Sugar-Sweetened Foods
Eggs
Cheese
Tofu
Margarine
Animal fats
Nuts
Carbohydrate Foods
Starch Group Includes breads, cereals, rice,
pasta, dried beans, starchy vegetables
Carbohydrate Foods
Fruit Group Includes all fruit (fresh, frozen,
canned, dried) and fruit juices
Carbohydrate Foods
Milk Group
Includes all milk and yogurt
Carbohydrate Foods
Non Starchy Vegetables Contain roughly 1/3 of
the carbohydrate of starchy vegetables
Carbohydrate Foods
Foods for Occasional Use
Carbohydrate Considerations
So you know…
• Convert to glucose starting in 10 minutes—100% 2 hours
• Snacks may be offered to meet nutritional needs, but not
required if diabetes management plan is appropriate
• Clear and Full Liquid Diets should NOT be sugar-free,
unless carb level met (3 carb choices/meal for women and
4 carb choices for men).
• Enteral Nutrition and TPN often cause hyperglycemia
– Beware of hypoglycemia when:
• Tube/IV dislodges
• Feeding/infusion D/C temporarily
• Reduction in rate
Diabetes Diets
Menu/Tray Ticket Updates
• Carbohydrate info for menu selections is essential to
integrate patient’s intake with their insulin or oral
diabetes medication regimes
• Carbohydrates per food item will be on:
– MNM Menu: Both choices and grams (at next
reprinting)
– Tray Ticket: Only grams listed
MNM Patient Menus
MNM Patient Menus
Range of Carbohydrate Grams / Choice
Tray Tickets
• Beginning in mid-late May,
all tray tickets will have
carbohydrate grams listed
next to food items containing
carbohydrates.
• If a food item has less than
2 grams per serving, it will
NOT appear on the tray
ticket.
• You will only have to
calculate carb grams
consumed, if there is a
prandial order to dose mealtime insulin on carb grams
consumed.
Calculating Carb
Grams Consumed
• Nurse, PCT, or Ambassador
to write fraction of food
consumed, next to food item
• Multiply fraction consumed by
grams, this will give you
grams consumed.
• Total all the grams consumed.
• Divide grams consumed by
insulin:carb on prandial
orders.
• Example:1 unit for 15 g carb:
31.25g / 15g = 2.08 units or 2
units. ALWAYS round down to
whole number, unless told
otherwise.
Nutrition Labels:
Carbohydrate Grams Counting
1. Note Serving Size
2. Note Total
Carbohydrate Grams
• Dietary Fiber and
Sugar are
included in Total
Carbohydrate
3. Calculate Carb
Grams based on
actual serving size
Diabetes Diets
Inappropriate Diet Orders
• There is no “ADA Diet”
– The American Diabetes Association does not
endorse any single meal plan or specified
percentages of macronutrients
• Meal plans such as “no concentrated sweets,” “no
sugar added,” and “liberal diabetic” diets are NOT
appropriate
– Unnecessarily restrict sucrose
– Implies that simply limiting sugar will improve
glycemic control
MNM DM Appropriate Diet Orders
Carbohydrate Gram Counting
– Identifies exact number of carbohydrate grams per
meal/snack
– Insulin to carb ratio is used to calculate the amount
of rapid-acting insulin needed to “cover” the grams
of carbohydrate consumed
– Ideal for intensive insulin therapy when tighter
control is desired particularly CSII, Gestational
Diabetes, Type 1.
Carbohydrate Counting
Food Log
• Can be ordered via CPOM/Diet Orders: Food Log
• Stored at HUC station on all units
• Calorie counting now on Food Log
MNM DM Appropriate Diet Orders
Carbohydrate Choice
a.k.a. Consistent Carbohydrate
• Goal: Consistent amounts of carbohydrates meal to meal
and day to day.
– May be some variation between meals, per patient
preference
– Based on heart-healthy diet principles
– Foods containing sucrose may be included, counted
as part of the total carbohydrate allowance
MNM DM Appropriate Diet Orders
Carbohydrate Choice
• Designated on CPOM diet order
• Default:
– Male: 4 carb choices/meal
– Female: 3 carb choices/meal
• Prandial insulin is given based on provider ordered
number of carbohydrate choices for each meal e.g. 4
carb choices/meal
• Effective if the patient is eating consistently
Carbohydrate Choice Diets at MNM
• 2 Carb Choices/Meal
• 3 Carb Choices/Meal
• 4 Carb Choices/Meal
• 5 Carb Choices/Meal
• 6 Carb Choices/Meal
Carbohydrates
Points to Remember
• Carbohydrate grams listed on food package Nutrition
Facts label can be converted to choices
– Teach 15 grams=1 choice
• Significant deviation from the carbohydrate plan
resulting in poor glucose control (high or low) should be
reported to the provider for modification to insulin
orders
Module 3:
Insulin Safety & Administration
Safety Takes A Vigilant Team
Communication Critical
Provider to/from Nurse
Orders appropriate
Documentation prompt/accurate
Complications addressed
Ambassadors to Nurse/PCT
BG check before meals
Noting amount eaten on tray
slip/to nurse
Nurse to/from PCT
Huddle at change of shift
Clear expectations
Prompt reporting
BG results
Tray slip/amt eaten to nurse
Nurse/Patient to/from Inpt DM
Educator/Dietitian
Advanced education
Management problem solving
Nurse to/from Patient
Education early/often
Symptoms reported/responded to
Alert to meal ordering
Glycemic Control Team to Team
Trends identified
Recommendations made
Nurse to Nurse
Change of shift report
Plan of Care
MNM Insulin Safety
Top Issues: 2012-YTD
• Missed orders:
– Watch for paper orders
o 4-36 hour delay
– Place upper section into CPOM
– Attach new order onto Diabetes Record (pink sheet)
• Acting without an order
– Holding/changing doses without/outside parameters
• Hypoglycemia
– Over/under/improperly treating
– Not reporting to provider
• Good job!
– Scanning 30,000 insulin administrations/year
– Low error rate
– Remember visual verification
FlexPen – Single Patient Use!
FlexPen
Safe Practice Recommendations
• Ensure that the patient name on the pen is verified
against the patient’s wrist band prior to administration
• The use of an insulin pen for more than one patient,
even with a needle change may result in transmission
of:
– Human Immunodeficiency Virus (HIV)
– Hepatitis B
– Hepatitis C
– Other blood borne pathogens
• Do NOT withdraw insulin from pen
FlexPen
Patient Education Considerations
• Different needles than at home
– We have auto cover for safety
– They will have 2 covers to remove
• Teach patient to prepare/give own injections as
appropriate
Insulins & Action Times
Category
Insulin Name
Levemir
Onset
3-4 hrs
Peak
Flat Peak
Duration
Up to 24 hrs
Maximal
Duration
24 hours
Long Acting
Rotate Sites
Lantus
4-6 hrs
5-15 mins
No Peak
Broad
24 hours
10-16 hours
Analog
Combinations HumuLIN 70/30 &
NovoLIN 70/30
5-15 mins
Broad
10-16 hours
Intermediate
30-60 mins
Broad
10-16 hours
HumaLOG 75/25
NPH
NovoLOG/HumaLOG 5-15 mins
30-90 mins < 5 hours
Aprida
Regular
30-90 mins < 5-8 hrs
2-3 hrs
5-8 hours
Rapid Acting
Short Acting
Comments
5-15 mins
30-60 mins
24 hours
Normally
dosed before
breakfast and
dinner
Normally
dosed before
breakfast and
dinner
U-500 Insulin – HIGH ALERT Medication!
Humulin Regular U-500 Insulin Considerations
• Contains 500 Units/mL (5x the “normal” U-100 conc.)
• Different peak & duration than Regular U-100
– Onset of 30 minutes
– Relatively long duration of action – most patients
can be managed with 2-3 injections/day
• There is no U-500 Syringe – outpatients often use a U-
100 syringe. This can lead to significant dosing errors
and confusion when taking medication histories
U-500 Insulin – HIGH ALERT Medication!
U-500 Insulin Safe Practice Procedures
• Only patients who were receiving U-500 insulin prior to
admission may receive this product while hospitalized
• Pharmacist verifies U-500 dosage via patient interview
and documentation from primary prescriber or
outpatient pharmacy
• Use of patient’s own supply of U-500 is prohibited
• Vial is NEVER dispensed to the nursing unit
• All doses are drawn up and dispensed from pharmacy in
a 1mL (TB) syringe.
• Double check system in place prior to dispensing from
pharmacy & prior to administration by nursing
Insulin – Sites of Administration
Fastest to Slowest Absorption Rates:
1. Abdomen
2. Back of upper arm
3. Front and upper side of
the thigh
4. Upper and outer part of
the buttocks (p.19)
Included in MNM Diabetes Education book pg. 19.
Supporting reference McCulloch, David MD Patient
Information: Diabetes mellitus type 1: Insulin
treatment (Beyond the Basics) www.uptodate.com
Accessed 6/7/2013
Insulin Therapy Terminology
Basal Insulin
(a.k.a. Background insulin)
•
•
•
•
•
Long-acting:
• Detemir (Levemir) (MNM standard)
• Glargine (Lantus)
Covers normal body processes that require insulin
Usually taken once daily (bedtime), but can be taken
twice daily.
GIVEN EVEN IF NPO
Typically administered as ~50% of the total daily dose
(TDD)
Insulin Therapy Terminology
Prandial Insulin (meal-time)
(a.k.a. Nutritional Insulin or Meal Bolus)
• Rapid-acting:
– NovoLOG (MNM standard)
– HumaLOG
– Apidra
• Covers the carbohydrates that a patient consumes at
meals and occasionally snacks
• Typically administered as ~50% of the TDD, split between
3 meals, or based on an insulin to carbohydrate ratio.
Prandial Insulin (meal-time)
When to Give:
• Give prior to meals if dietary intake is good and
certain
– Ideally 15 minutes before eating, to be available
once carbs are starting to be digested.
If Chance Patient Might Not Eat:
• Give after meals if dietary intake is uncertain
• If <50% of meal eaten, lower dose by 50%.
• Hold if NPO
Insulin Therapy Terminology
Insulin to Carbohydrate (Carb) Ratio:
• The number of carbohydrate grams that requires
1 unit of rapid-acting insulin (NovoLOG) as Prandial
Insulin
• Most adults will require 1 unit to 15 grams of
carbohydrate (1:15); however, this ratio can vary from
person to person and can even vary from meal to meal.
One Carbohydrate (Carb) Choice = ~ 15 grams of Carbohydrate
Calculating Dose
• Prandial order: 1 unit
NovoLOG for every 10
grams of carbohydrate
consumed.
• Example: Patient
consumed 31.5 g of the
57 g carbohydrates
available for the meal.
• Calculate Insulin dose:
31.5 g carbs ÷ 10
units/g = 3.15 units =
3 units. Round down to
the nearest whole
number, unless
otherwise ordered.[?]
Calculating Dose Examples:
• Prandial dose ordered: 1 unit of NovoLOG insulin for
every 15 g of carbohydrate consumed.
– 53 grams of carb consumed.
53 g ÷ 15 units/g = 3.5 = 3 units (always round down
to whole unit).
• Prandial dose ordered: 1 unit of NovoLOG insulin for
every 10 g of carbohydrate consumed.
– 77 grams of carb consumed.
77 g ÷ 10 units/g = 7.7 = 7 units (always round
down to whole unit).
Documentation of Insulin for Carb Intake
New field on orders for NovoLOG Insulin that is
used in conjunction with Carbohydrate Grams Diet Order
[Sue to confirm here through 56 with IT]
• Order is entered as a freetext dose directing RN to See Comments
• Scan NovoLOG pen and RN receives this message:
• Click OK and proceed to Documentation Screen
Documentation of Insulin for Carb Intake
Complete the required documentation in the fields indicated:
• Carbohydrate Intake (grams)
• Number of Insulin Units: Type in Number & then U for Unit(s)
• Site of Administration
•
In this example the order was to give 1 Unit of NovoLOG for every 10 grams of
Carbohydrate Intake. Patient ate 77 grams of Carbs; so the NovoLOG dose is 7 Units
Insulin Therapy Terminology
Correction Scale Insulin
(a.k.a. Supplemental insulin) Old terminology: “sliding
scale”
• Rapid-acting insulin (NovaLOG) given to bring blood
glucose level into range. Given in addition to basal and/or
prandial insulin.
– This is used in the event the basal insulin dose is not
adequate; it should not be the sole insulin ordered longterm.
– If its use is required for 24 hours, notify provider for
potential adjustment to insulin regimen.
— Correction dose can be combined with Prandial dose and
given premeal (if anticipated intake certain) otherwise, give
separately in response to ordered blood glucose monitoring.
Documentation of Correction Scale Insulin
• Order is entered as a freetext dose directing RN to See Comments
• Scan NovoLOG pen and RN receives this message:
• Click OK and proceed to Documentation Screen
Documentation: Correction Scale Insulin
Complete the required documentation in the fields indicated:
• Number of Units of Insulin (Type in Number & then U for Unit(s)
• Site of Administration
Based on the Resistant Correction Scale
a Blood Glucose result of 374 mg/dL
would require coverage with 15 Units
of NovoLOG insulin
IV Infusion Protocol
Critical Care Administration
• Follow algorithm or call provider
• Document rate and changes on IAF
• SCIP Guidelines for Cardiac Surgeries:
– Post Op Day 1 & 2: BG closest to 0600 must be
<200 mg/dL
• Transitioning to SC:
– Initial Dose of Basal Insulin must be given 2 hours
prior to discontinuing the IV Insulin infusion!
Module 4:
Special Situations
•
•
•
•
Continuous SQ Pumps
Pre-Op Patient Management
Dye Procedures
Diabetic Ketoacidosis
Continuous Subcutaneous
Insulin Pump (CSII)
• Follow MNM Administrative Policy # TX.118 found
under P&P on the Intranet.
• Contraindications:
Altered state of consciousness
Risk for suicide
Unable or unwilling to participate in care
CSII - continued…
• The patient MUST sign the age appropriate CSII
Therapy Agreement (for minors the guardian must
sign).
• The patient MUST agree to let the pharmacy
personnel download the pump within 6hrs of
admission.
— Complete ASAP, as information is important in determining
appropriate insulin doses.
• The physician MUST order the insulin basal, prandial,
and correction doses. The sensitivity factor and
targets should also be ordered by the physician.
CSII - continued…
• The patient MUST bring all supplies for the pump.
• The insulin will be provided by the hospital
pharmacy.
• The Dietitian, Diabetes Educator and Endocrinologist
MUST be consulted on CSII patients.
CSII - continued…
• For any radiology procedure the pump MUST be
removed and secured in the patients medication
drawer. On return the pump MUST be reinitiated
immediately.
• The patient MUST be evaluated on an ongoing basis.
If there is any change in mental status the physician
MUST be called to dc pump and start subcutaneous
insulin.
MNM Administrative Policy TX.118
CSII
Process
• Only if patient can manage
• Agreement
• Remove to download, shower, radiology procedures
• Orders
• Use our meter
• Setting/tubing/site changes made by patient
• Auto consult to Inpt DM Clinician, Dietitian
• Record setting changes on pink sheet
Preop
PRE-PROCEDURE INSTRUCTIONS FOR/
MANAGEMENT OF DIABETES PATIENT
IN OUTPATIENT SETTING (including AM Admit)
Protocol 511200
Nursing
Management
on Admission
FBS
If less than
70mg/dL:
Hypoglycemia
Protocol 999.235
If greater than
200mg/dL: Notify
physician
(See Abnormal
Result Algorithm)
Report if
discrepancy
between
instructions and
patient
compliance
Patient’s Routine
Diabetes Medication
Preprocedure Patient
Instructions
(See Classifications Below)
 Short Acting Insulin*
 Oral Agent
 Injectable (Byetta, Symlin)
Hold a.m. of procedure
 Intermediate Acting
Insulin**
Take half of usual a.m. dose
 Long Acting Insulin***
Single p.m. dose
If normal 10pm dose 20 units or less: usual p.m. dose
 Long Acting Insulin***
Single a.m. dose

If normal dose 20 units or less: full usual dose
If normal 10pm dose greater than 20 units: half p.m. dose
If normal dose greater than 20 units: half usual dose
1. Full p.m. dose
2. --If normal a.m. dose 20 units or less: Full a.m. dose
--If normal a.m. dose greater than 20 units: Half a.m. dose
 Long Acting Insulin***
Twice a day dosing
 Call Diabetes Nurse Clinician (Kathy Bowers) ideally 3-14 days before procedure
 Continue Basal infusion only. Lower to half if BG 110 mg/dL based on evaluation at preVerify pump is
outside operative
field and infusing
at basal rate
Type 2 DM: Give
half usual a.m.
dose as NPH
Start time
11 a.m. or
later
procedure medical evaluation.
 Insulin Pump
 Change insertion site and reservoir the morning of surgery and bring extra supplies (insertion
set, reservoir, extra batteries)
 Place pump catheter outside operative field (e.g. for abdominal surgery use hip, thigh or arm)
 Radiologic procedure: remove pump from room. Consider alternative glycemic treatment
 Mixed Insulin****
Type 1 DM: Nurse to call anesthesiologist on call/physician in
charge as appropriate for instructions
Type 2 DM: Hold insulin (given by nurse on arrival at hospital)
Follow
above
and…
Patient to check
Blood Glucose
(BG) upon waking
in a.m. and every
4 hours until
arrival at hospital
Insulin Classifications
*Short Acting Insulins
 Humulin R
 Humalog (Lispro)
 Novolog (Aspart)
 Apidra (Glulisine)
**Intermediate Acting
Insulins
 Humulin N
 Novolin N
 NPH
Revised 5/2/08 Dr. Cartwright
Reformatted 8/5/09 Diabetes Task Force DRAFT 1/9/12
 Patient to call Ambulatory Surgery Team Leader if BG greater
than 200mg/dl. (Nurse notifies appropriate physician)
 Patient to call Ambulatory Surgery Team Leader if BG less
than 100mg/dl. (Nurse notifies appropriate physician)
o If BG is less than 70mg/dL: instruct patient take 4
glucose tablets OR 15 grams of glucose gel OR 4oz
clear apple juice. Repeat BG level after 10-15 minutes. If
less than 80mg/dL, repeat treatment and checks until BG
is 80mg/dL or greater.
***Long Acting Insulins
 Lantus (Glargine)
 Levemir (Detemir)





****Mixed Insulins
Humulin 70/30
Humulin 50/50
Novolin 70/30
Humalog Mix 75/25
Novolog Mix 70/30
Pre Procedure
Potential Dye Issue
• Radiologic (X-ray) studies involving the use of
intravascular iodinated contrast materials (dye), e.g.:
intravenous urogram, IVP, intravenous cholangiography,
angiography, and computed tomography (CT) scans can
lead to:
– temporary renal (kidney) function changes
– rare cases of lactic acidosis
• Metformin containing medication should be temporarily
discontinued at the time of, or prior to the procedure,
and not taken again until 48 hours after the procedure.
• Metformin/medications that contain Metformin:
– Glucophage, Actoplus Met , Avandamet , Fortamet ,
Glucovance, Glumetza, Janumet, Jentadueto, Kazano,
Kombliglyze XR, Metaglip, PrandiMet, Riomet
Diabetic Ketoacidosis (DKA)
Emergency Situation
• Fluids
– 3.5-5 L in first 5 hours
– 250-500 mL/hr, hours 6-12
• Electrolytes
– K+ replace when <5.2 mEq/L
– Goal 4-5.1
• IV insulin
– When K+ >3.3
– Bolus: 0.15 units/kg
– Infusion 1 unit/mL, 0.1 unit/kg/hr until resolved
• Monitoring
– Hourly
– Goal: drop 50-75 mg/dL/hr to 150-200mg/dL
Module 5:
Hypoglycemia
Hypoglycemia
What to Watch For
• Hypoglycemia: any BG <70 mg/dL
• Severe hypoglycemia <40mg/dL
• Key predictors:
–
–
–
–
Older age
Advanced DM
History of frequent hypoglycemia
Malnutrition
• Hypoglycemia (both clinically mild and severe) is
associated with an increased risk of mortality:
–
–
–
–
Cardiovascular disease
Irreversible brain damage
Coma
Death
HealthDay News, Risk of Comorbidities Up with Hypoglycemia in T2DM. April 8, 2013
Treatment Protocol
When to Start
• Exhibits signs (treat without waiting to check BG, but
check ASAP for close to baseline reading):
– Shakiness/Tremors/Tingling in extremities
– Decreased concentration/Anxiety/Irritability
– Sweating/Changes in body temperature
– Increased BP/Cardiac arrhythmias/Palpitations
– Headache
– Dry mouth/Hunger
– Restless sleep
OR
• BG <70 (without symptoms)
<70
Treatment Protocol
If patient able to take oral safely:
• Have patient ingest 15 gms of oral glucose
Examples: 15 gms of glucose gel
or
4 ounces (1/2 cup fruit juice)
– Fiber does not increase BG
– Dietary fat slows digestion, delaying rise
– Protein has no effect
Treatment Protocol
If patient unable to take oral safely or NPO:
• If IV access:
– D50—25 mL (12.5 gm) IV
or
• If no IV:
– Glucagon 1 mg SC or IM
Position on side to reduce chance of aspiration
Treatment Protocol
Evaluate/Subsequent Treatment
• Wait 10-15 minutes, recheck--If less than 80, retreat/
repeat as needed

<80
• If pt. has CSII(pump) place in suspend/stop mode notify
physician
Treatment Protocol
If/when patient able to take oral safely:
• If meal won’t be eaten within 2 hours, have patient eat
snack (carbohydrate, NOT fat)
Treatment Protocol
Notify Provider
• Change in glycemic control plan e.g. insulin orders may
be warranted
CALL ALL
• Resume CSII at same or different basal rate as ordered
Module 6:
Diabetes Management Across
the Continuum
Home to Hospital to Discharge
Documentation of Meds by Hx - Insulin
Tips for Success in Documenting Home Insulin Regimens:
• Use the Insulin folder:
• Select the correct product based on what the patient uses at home:
• Note: pens have the word “Pen” in their description
• Use the correct unit of measure for insulin: unit(s)
• Questions to ask regarding Correction (sliding scale) Coverage:
o Do you have a copy of your scale?
o What is the highest number of units in your sliding scale? or
o How many units would you give if your blood sugar was 400?
o How often do you check your blood sugar to give a correction dose?
Documentation of Meds by Hx - Insulin
Example:
• Patient says they use NovoLOG – it comes in a vial
• Patient doesn’t know their actual scale, but do tell you that they would
give 12 units if their blood glucose was over 400
• Patient checks their blood glucose before meals, but not at bedtime
Documentation:
• Open the Insulin Folder & Select:
• Dose Field: 12 unit(s)
• Frequency Field: AC Meals
• Order Comments: 0-12 units based on sliding scale
Documentation of Meds by Hx - Insulin
Finished Example:
Order Comments:
Hospital Diabetes Management
Improvements to Current System:
• Updates to Order Form
• Wireless Glucometers
• Glycemic Control Tab in Power Chart
Coming Fall of 2013:
• CPOM for all Insulin & Diabetes Related Orders
Changes to Current Order SQ Insulin Form
Changes were made in May 2013 to address known issues and to get
us in line with the eventual CPOM Insulin Power Plans:
• Order to Discontinue all previous insulin orders changed to:
• Discontinue previous subcutaneous insulin orders
• Rationale: we do have patients that receive both IV and SQ Insulin
• Basal Insulin Section:
• Added options for NPH and Humulin 70/30 insulin with appropriate
administration times of Before Breakfast and Supper (not AM & HS)
Current Paper Order Form for SQ Insulin
• Prandial Insulin Section:
• Added wording for appropriate administration timing of prandial
insulin dose based on patient’s dietary intake:
• Give prior to meals if dietary intake is good and certain. Give after
meals if dietary intake is uncertain. If less than half of meal eaten,
lower dose by 50%. Hold dose if NPO.
• Reformatted Carb Coverage section to match the required format for
the CPOM Carb Coverage Power Plan
Changes to Current Order SQ Insulin Form
Biggest Change: Correction Scale now starts at 150!
• Correction Scale Section:
• Coverage will begin with a Blood Glucose of 150 mg/dL
• This keeps the coverage scales in line with typical out-patient regimens
Changes to Current Order SQ Insulin Form
What Does Not Change:
• Nursing will continue to order Hypoglycemia Protocol and Labs
• Pharmacy will continue to enter insulin orders
Wireless Meters
• Updated procedure for everyone to read to be available
on McLaren University.
• Upgraded meters arrived in June
• Training schedule do be determined: some classroom sessions
and some rounding in-services.
• We will have up to four trainers at one time and plan to offer
training for 5 days prior to go live.
• Inform II: screen function is the same as our current meter
with some differences in how you dose the strip and how the
meters get docked and transmit results.
• The strip methodologies are different but the meter function is
the same. I anticipate a 30 min class time and this would
include them taking a competency exam.
Glycemic Control Tab
Available Now in Power Chart - found under
the Results Tab
Data Available on the Glycemic Control Tab
• Blood Glucose & Hemoglobin A1c Results
• Insulin doses administered including IV infusion rate – must
document Insulin Infusion on IAF
• Hypoglycemia treatments administered (dextrose, glucagon,
and eventually orange juice)
• Oral diabetic agents administered
• Steroid doses administered
• Carbohydrate (grams) consumed (if Carbohydrate Grams Diet
is ordered)
Glycemic Control Tab – Group View
• Can switch between Table, Group and List Views to organize the
data in different ways
Glycemic Control Tab – Future Role
• Replacement for the Pink Sheet in conjunction with CPOM
Insulin Go-Live
• Familiarize yourself with the information on the Glycemic
Control tab so you are better prepared in the fall
• Your documentation “feeds” the Glycemic Control Tab
•
•
•
•
Insulin SQ Doses
IAF Documentation of Insulin Infusion Rates
Oral Diabetic Agents
Hypoglycemia Treatments
Electronic Orders
• Implementation of CPOM Insulin Power Plans
is currently slated for the Fall 2013
CPOM Components for Diabetes
Management
• Variety of Power Plans being developed to mimic
current paper orders for:
— Subcutaneous insulin regimens
— IV insulin infusions
— One-time insulin orders
• DKA Power Plan: improved for phased treatment
of the patient with DKA or HHS
• Reference Text attached to power plans to help
guide therapy
• Diabetes Discharge Prescriptions and Plan
Discharge
Start on Admission
• Education
– Diabetes Education Book
o Sick day management: pg 13
– New videos (2N/2S TL)
– Patient Education Channel 39: Guide on Intranet Library
tab/Clinical Resources
– ExitCare
– Return demo
– Inpatient Clinician/Dietitian consult
• Insulin Pen
– Pen from drawer must be labeled for outpt use
• Paper prescriptions
–
–
–
–
Pen/Needles
Vial/syringe if no insurance
Glucometer/strips
Outpatient DM & Nutrition Counseling Center
Resources
• Yale Book
• CPM Guidelines
• CSII website
• ADA
• JCAM 2012
• Medtronic carb counting
Questions?