Transcript JIIP Protocol - Jefferson University Hospitals

A Nurse Managed Computerized
Program For Continuous IV Insulin
Infusion:JIIP(Jefferson Insulin
Infusion Protocol) and Non JIIP.
Joan Moshang RN BSN MEd. CDE
CIII Program Content

Indications for JIIP and NON-JIIP

Physician,Nurse and Pharmacy
responsibilities.

Practice Pathway for Titrating JIIP.
Requirements:
RN will review the PowerPoint
presentation.
 RN will practice titration guidelines
on practice pathway on computer.
 RN will complete program quiz with
a grade of 100%.
 Unit CNS will review quiz results
with staff member.

Introduction




Uncontrolled hyperglycemia in
hospitalized patients results in poor
clinical outcomes.
IV insulin is the drug of choice for optimal
glycemic management in many patients.
Safe administration of IV insulin is a
complex task.
The Jefferson Hospital Insulin Infusion
Protocol(JIIP) applies to all adult patients
requiring IV insulin but ONLY if the JIIP
is ordered.
General Guidelines

Physicians who do not order the JIIP but
want continuous IV insulin infusion (NONJIIP) for their patients, are responsible for
the hourly titration of the infusion and
specific fluid orders.

The RN may titrate a non –JIIP infusion
based on previous infusion guidelines
online but only if the glucose and
piggyback protocol is followed.
SO….

JIIP is a Jefferson Hospital nurse managed
protocol for delivering continuous IV
insulin.

Non JIIP Continuous IV insulin infusion
orders are titrated hourly by the ordering
physician and must comply with the
glucose and piggyback guidelines.

RN may not hang an insulin infusion that is
not piggybacked into another IV.
JIIP Candidates

ICU patients with BG>180mg/dl x 2
consecutive measurements.

NOTE: Check Blood glucose (BG) on
admission to ICU and q4 hours thereafter. If
BG <140mg/dl for first 24 hours, measure
BG daily or as clinically indicated.
JIIP Candidates
All
other patients with BG >250mg/dl x 2
consecutive readings after initial oral
diabetes medications or insulin therapy have
failed.
All
DKA (Diabetic Ketoacidosis) or /HHS
(Hyperosmolar Hyperglycemic State)-See
separate guidelines for management of DKA
and HHS.
JIIP Candidates

Type 1 DM requiring surgery/general anesthesia.

Type 2 DM with uncontrolled hyperglycemia or
insulin requiring type 2 DM needing
surgery/general anesthesia.

Note: It is best to start an IV insulin infusion the
night before surgery. (Suggest Endo Consult for
insulin orders.)

Never discontinue insulin on patients with type 1
diabetes. If BG 70 or less,follow hypoglycemia
protocol and restart insulin when BG normal.
More Pearls
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
Once the JIIP protocol is initiated, all
other insulin orders are discontinued,
including CDI(Correction Dose
Insulin) and insulin in TPN bag.
TJU Blood Glucose (BG) goals:
140-180mg/dl while on infusion
70-140mg/dl while off infusion
Blood glucose may NOT be decreased by
more than 100mg/dl/hr.
PRECAUTIONS/WARNING

Patients with liver failure ,s/p liver transplant
or ESRD(End stage renal disease) may need
to be excluded from the protocol. Consult
Attending physician.

On general and intermediate care floors,if
insulin rates > 10 units/hour, notify House
staff or Attending to determine if protocol
should continue.

In ICU,insulin rates > 20units/hour
must be OK’d by Attending physician.
Endocrine service may be consulted in these
circumstances.
IV Fluid Guidelines


ALL patients with Blood glucose
(BG)<250mg/dl must receive a minimum
of 5gm of glucose/hour as:
D5/W, D5/NSS or D5/1/2NSS @100cc/hr.
or a D10 solution at 50cc/hr.
CAUTION: post cardiac surgery DM patients
on epinephrine should NOT receive D10 at
greater than 25cc’s/hr.
Infuse D5 @50cc/hr.or D10@ 25cc/hr.)
RULE OF THUMB
Patients with BG <250mg/dl NOT
receiving a source of
dextrose/glucose cannot be on
the JIIP.
Attending physician must be
notified for further instruction.
Rationale
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The inclusion of D5/W piggyback solution
is a safety factor designed to avoid
hypoglycemic events.
All Continuous Intravenous Insulin
Infusions (CIII )MUST be piggybacked into
another IV solution.
Normal saline or D5/W at a “Keep open”
rate is acceptable only if the patient is
receiving tube feedings providing a minimum of 120 grams carbohydrates/day.
Key Points

Continuous IV insulin infusions (CIII)
are either JIIP or NON-JIIP.
 Infusion rates >than 10units/hr on general floors
and >20 units/hr in ICU’s must be OK’d by
physician.
 Insulin infusions MUST be piggybacked into
another appropriate solution.
Physician Responsibilities
 Physician enters order for JIIP and orders
the bolus dose and the initial infusion
rate as follows:
 Non DKA/HHS ex: (Pre-surgery, uncontrolled
hyperglycemia,NPO post surgery etc.)
 Divide initial BG by 100 and round to nearest
0.1unit.
(Ex: Current BG 200 divided by 100=2 units
bolus and 2 units/hr.)
Physician Responsibilities
 DKA/HHS
 Calculate dose as 0.1units/kg
(Ex: Weight in Kg.= 50 Kg x 0.1=5 Units
bolus and 5units/hr.)
Note difference between bolus and
initial start rate of DKA/HHS AND
NON DKA/HHS.
DKA/HHS(HHNK)
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In addition to ordering the different bolus
and initial infusion start rates for
DKA/HHS, the physician must refer to
DKA/HHS guidelines for BOH(Beta
hydroxybuterate),anion gap,Potassium
and fluid guidelines.

Once the bolus and initial infusion rates
are administered,both DKA and NON-DKA
are titrated by the RN according to the
JIIP table.
DKA/HHS cont.

Patients in DKA on JIIP or Non JIIP with
ketones present must remain on the
infusion until their ketones are
normalized, even if the BG is
normal.Check the BOH(beta
hydroxybuterate) and/or anion gap and
the DKA guidelines.

(Must maintain insulin rate at minimum of
0.02 units/kg/hr. Ex:70kg
pt.x0.02=1.4units/hr.)in patients with
DKA/HHS
For DKA/HHS Drip Titration:
a. If Insulin Rate calculation less than 0.02 unit/kg/hr
there is a pop up warning stating:
The calculated rate is less than 0.02 unit/kg/hr
and a potentially suboptimal low insulin
infusion rate. Please call physician to
determine the appropriate amount of Dextrose
IV.
a. If BG less than 250, there is a pop up stating:
Recommend IV fluids D5 at 150- 250 cc/hr
DKA/HHS(HHNK)
Patients in DKA with a normal or near
normal BG
…but still spilling ketones
…will require a higher hourly rate of
glucose to allow for continued insulin
administration. Call physician for order
change.
Rationale

The Blood glucose is usually corrected before
the ketones are cleared. Premature
discontinuation of the insulin infusion will
cause a rebound effect.
Caution!


Note: although the physician is
responsible for entering the correct order
set, the RN must recognize the difference
between DKA and non-DKA management
guidelines for safe patient care.
When communicating with the
physician,always state if patient has
type 1 or type 2 DM.
FYI: Physician Order Sets

Include “pop ups” for DKA/HHS
management including Potassium and
fluid guidelines.

Multiple “pop up” reminders for
monitoring, transition to
subcutaneous insulin etc.
Pharmacy’s Responsibility

Pharmacy prepares and labels the
infusion:100 Units regular insulin in
100cc’s NSS.

Pharmacy prepares and labels the bolus
dose ordered by physician:
-If not DKA/HHS,
Initial BG divided by 100 and
rounded to nearest 0.1unit.
-If DKA/HHS, 0.1unit/kg.
Nursing’s Responsibilities
2 RN’s view the order and verify the
label and rate changes.
 RN flushes IV line with 20cc of infusion
to saturate insulin binding sites in
tubing.
 2 RNs administer the IV bolus and
initiate the infusion at rate ordered by
physician.
 2 RNs titrates infusion as determined by
calculations on insulin table.

No protocol trumps
clinical decision making.
The RN must be vigilant in: --assessing
patient for nutritional changes,
-meds which can increase or decrease BG
values, fever ,etc.
-Reason for infusionDKA,Surgery,uncontrolled hyperglycemia?
(the bolus and start rate depend on the
reason why the infusion was initiated).
Insulin Rate Adjustment table
You must use the computer table to
calculate rate changes.
 A practice pathway will be available
on each unit.
 The table addresses rate change
only.
 For safe patient management,you
must be aware of changes such as
NPO status, steroid induction,
clogged feeding tubes etc.
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IN A NUTSHELL:
Physician places order.
 Pharmacy prepares fluids and bolus
dose.
 2 RN’s check order which includes
bolus and initial infusion rate.
 RN administers bolus and starts
infusion and enters current BG.
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RN
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Rechecks BG in one hour,enters
current BG on MAR and based on
current and previous BG results:
clicks
on insulin rate tab (Bottom left of
screen) and titrates according to the rate
calculated by titration table.
HOW’d THEY DO THIS??

Endocrine reviewed multiple adjustment
guidelines .

Inserted multiple case scenarios and
developed titration table.
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Following are examples of how the
titration units were determined..

(For information only):You will not see this on the
viewer)
≤ 70
71-99
100-140
(120)
141-180 181-240 241(210)
300
STOP‡
Stop*
Stop#
Stop#
Stop#
Stop#
Dec by 50 - 100 STOP‡
Stop*
Stop#
Stop
Dec by
50%
Dec.by
25%
Dec by 25 - 49
STOP‡
Stop*
Stop#
Dec. by No
25%
change
No
change
Dec or Inc by 0
- 24
STOP‡
Dec by Dec. by
50%
25%
No
change
Inc. by
50%
Inc by 25 49
STOP‡
No
No
change Change
# Stop
Infusion for 15
Inc by
Inc by
Inc. by
minutes. Restart @50% of
25%
25%
50%
previous rate. Make sure
D/5 or D/10 is added.
Inc by ≥ 50
STOP‡
No
Inc by
change 25%
Inc by
25%
Current BG
∆ in BG
Dec by >101
Inc by
25%
Inc by
50%
Inc.by
100%
≤ 70
(65)
71-99
100-140
141-180
(150)
181-240
241300
∆ in BG
Dec by >101
STOP‡
Stop*
Stop#
Stop#
Stop#
Stop#
Dec by 50 - 100
STOP‡
Stop*
Stop#
Stop
Dec by
50%
Dec.by
25%
Dec by 25 - 49
STOP‡
Stop*
Stop#
No
change
No
change
Dec or Inc by 0 24
STOP‡
Dec by
50%
Dec. by
25%
Inc by
25%
Inc. by
50%
Inc by 25 49
STOP‡
No
change
No Change Inc by
25%
Inc by
25%
Inc. by
50%
Inc by ≥ 50
STOP‡
No
change
Inc by
25%
Inc by
50%
Inc.by
100%
Current BG
Dec. by
25%
No
change
Inc by
25%
ALL BG’S<THAN 70mg/DL.
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STOP INFUSION:Obtain lab serum glucose
and document symptoms on hypoglycemia
schemata.
For BG 40-70mg/dl:
Able to take oral: give 15 grams of oral glucose.
Unable to take orals :1mg glucagon SC/IM or
If altered consciousness,give ½ amp D50
(12.5gm)
Recheck BG q 15minutes until BG >100mg/dl
and restart infusion at 50% of previous rate.
Ensure D5 or D10 is added for BG<250mg/dl.
Blood glucose <40mg/dl
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Serum specimen to lab.
15Gm of oral glucose if able to take.
If altered consciousness:1/2 amp D50 IV.
If no IV access,give 1mg glucagon SC or
IM.
Recheck BG q 15 minutes until BG >
100mg/dl.
Restart infusion @50% of previous rate.
Key Points
The bolus dose and insulin start
rates depend on the reason for the
infusion.
 There must be a constant source of
glucose during insulin infusions.
 2 RN’s must verify rate changes.
 Hypoglycemia and critical value
protocols must be followed.

Monitoring
BG monitoring is done q 1hour until BG
140-180mg/dl for 2 consecutive
hours;then q2hours if no significant
change in status.
 Return to q 1hour monitoring if:
- Starting or stopping steroid therapy.
-Starting or stopping dialysis.
-Starting, stopping or rate change of
tube feedings or hyperalimentation.
-Infusion rate change.

Glucose Interruptions

If BG < than 250mg/dl and glucose
containing fluids are interrupted for
some reason, stop insulin infusion.

Check BG q 15 minutes until glucose
source restarted.

Restart insulin infusion.
Clinical Situations

Continuous Tube Feedings
-If receiving 120 gms of carbohydrate in 24
hours,may maintain D5W @40cc’s/hr.

Stopping tube feedings.
-To continue JIIP, must have glucose source
@100ml/hr.

-
Interruptions in insulin delivery.
Patient Transfers

Patients on JIIP who are transferred from
OR, ER etc. to a general unit:

Check BG immediately and again in 15
minutes.

Based on the 2 values,titration rates are
made according to the protocol.
Review section on Monitoring.
Transition To Subcutaneous Insulin

Do NOT D/C the infusion for patients with
Type 1 DM who are spilling ketones even
if BG is normal.

Never stop infusions during the night:prebreakfast or pre-dinner is optimal.

If ketones are controlled and BG is
180mg/dl or less, transition to sc insulin
is appropriate.
When Transitioning To Subcutaneous
Insulin:
Start subcutaneous Insulin PRIOR to the
discontinuation of insulin drip based on type
of insulin given. The best times for transition
are PRIOR to breakfast or dinner.
RECOMMENDED OVERLAP TIMES
Lispro or 75/25
15 minutes
Regular or 70/30
30 minutes – 45 minutes
NPH
2 hours
Lantus or Levemir 2-3 hours
Computer downtime

Click on clinician on Intranet.

Under clinical applications,scroll down to:

Insulin calculator for Jeff chart downtime.
Note: Actual calculator will be updated to reflect
use on all care units-not only Intensive care
units.
Proceed to quiz if you are able to:
State the rationale and indications for
continuous insulin infusions.
 State the bolus and insulin start rate
for DKA/HHS vs. Non-DKA/HHS.
 Utilize titration table correctly.
 Manage hypoglycemic events per protocol.
 State transition times from insulin infusion
to subcutaneous insulin based on type of
insulin ordered.

Must answer all questions correctly:
Circle correct answer.
1.Physicians may order the JIIP without piggybacking the infusion
into a main line.
True
False
2.The titration table is the same for both DKA/HHS and non
DKA/HHS patients.
True
False
3.Two RN’s must verify all rate changes. True
False
4.In the event of a clogged or dislodged feeding tube,it is important
to maintain a steady rate of insulin.
True
False
5.The blood glucose is often corrected before the blood ketones.
Therefore, maintain the insulin infusion in type 1 diabetics until
ketones are normalized even if the BG is normal.
True
False
Quiz continued:
6.The critical value protocol is the same whether on or off the insulin
infusion.
True
False
7.Blood glucose test results must be entered into the computer within
10-15minutes.
True
False
8.Insulin rate changes are based on the current blood glucose result.
True
False
9.Stop the infusion if BG <than 70mg/dl;restart @ 50% of rate when
BG is 100mg/dl.
True
False
10.Maintaining a normal BG and preventing hypoglycemia are the
main goals of continuous IV insulin therapy.
True
False
Unit CNS Responsibilities:
 Unit clinical nurse specialist will assume
responsibility for staff competence in
utilizing protocol.
 Will supervise staff proficiency with
practice pathway.
 Maintain records to reflect:
-Completion of Nurse Managed JIIP
power point and quiz with grade of
100%.
- Proficiency in use of training pathway.