Transcript Presentation

Best Practices in
Mealtime Insulin
Administration
By Diane Rolof, RN, BSN, CDE
Diabetes Consultant, Regional Health
Integrated Healthcare System
5 Hospitals
2 Long-term
Care
24 Clinics
Employ 5,000+ Providers
and Caregivers
Recognized for Quality & Patient Experience
ANCC Magnet Recognition® (Rapid City)
Trauma Verified
• American College of Surgeons Trauma
o Level II (Rapid City) and Trauma Level III (Spearfish)
• South Dakota Department of Health Trauma
Verification – Trauma Receiving Facilities
o Custer, Sturgis, Lead/Deadwood
AHA Get With the Guidelines Stroke Award
AHA Mission: Lifeline STEMI Award
Healthstream: Insight Award
• “Overall Patient Experience” (Custer)
Coverage Area
5 states | 250 mile radius
858,469 | South Dakota Population
373,618 | Service Area Population
Committed to the Future of Healthcare
32 Medical Specialties including:
Orthopedics, Cardiac, Cancer Care
Affiliations: 5 Schools of Nursing
Graduate Nurse Residency program
Medical Residency program
100+ active research studies
Objectives
1. Discuss a process to identify enhancers and barriers to
timely insulin delivery at mealtimes
2. Discuss a process that can be replicated that will
improve the timeliness of insulin administration
Enhancers and Barriers – Human Resources
• Nursing Evaluation Includes:
– Insulin Administration
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Insulin for carb intake and for glucose correction
Variation in education re pre-meal or post-meal
Variation in practice r/t education and “comfort level” of insulin timing
Plan for knowing how much carbohydrate was consumed and plan for
when pt. does not consume
– Oversight of Patient Care Technicians
• Patient care technicians serve under nurses – Nurses need to evaluate
patient care technicians practices r/t glucose testing and picking up meal
trays of patients that are receiving insulin for carbohydrate intake
Enhancers and Barriers – Human Resources
• Patient Care Technicians
– Pre-meal glucose testing
• Variation in practice r/t timing of glucose tests
– Tray delivery and pick-up
• Plan for notifying nurse how much CHO was consumed
• Scope of Practice in our state does not allow PCT’S to count carbohydrates
unless that have had a competency test on carb counting
• Dietary Staff
– Tray delivery
• Education regarding need for glucose check prior to tray delivery
– Tray pick-up
• Plan for notifying nurse how much CHO was consumed
Other Enhancers and Barriers
• Supplies Evaluation – available when needed
– Insulin pens and needles availability
– Glucose testing supplies availability
• Electronic Medical Record Evaluation
– Insulin orders define administration time
• Our orders state to give insulin for carbohydrate intake when the meal is
served or within 20 minutes of the first bite of the meal
– Process from glucose test until results in EMR
• Involve laboratory personnel to evaluate any issues with the glucose meters or
delays in transmission of the glucose readings to the EMR
• We require nurses to use the glucose test in the EMR rather than a hand
written note with result – too many errors with transcription can happen
– Process from medications scan to EMR
• Our scanning process when using insulin pens involves 3 scans
– patient name band
– insulin pen device (to verify the pen is only used on one patients
– insulin medication to verify right kind of insulin is being given
New Process to facilitate insulin is given within
45 minutes of the glucose test
• Glucose testing begins when meal trays arrive on the nursing unit
– Previously testing began when the staff anticipated the trays would arrive
• Meter is docked after each test
– Previously the meter was docked after all the glucoses on the unit had been
checked. Staff thought this was more efficient, but time studies demonstrated
that this perception was not valid
• Log kept to note if the glucose test has been completed
– Informs dietary staff the glucose test is done and the meal tray can be delivered
• Insulin is dosed off the glucose in the EMR
– To prevent errors r/t transcription
• Insulin is given as the meal is served or within 20 minutes of first
bite of the meal
– per standardized provider orders
• Systematic roll-out of process to all patient care areas
Evaluation
• Daily audits in each patient care area of the time from glucose test
until insulin was administered
– Audits were done by staff in the patient care unit
– This helped with accountability and also helped achieve buy-in from staff
• Celebrated the successes
– Kudos to individual staff and departments as we saw improvements
• Crucial conversations prn
– Nursing units manager were involved in audits and had conversations with
individual staff when improvement was needed
• Posting of results on the patient care areas
– Helped keep the process fresh in everyone’s mind
Our Results at End of Formal Audits
% of Aspart insulin injections given
within 45 minutes of the glucose test
Baseline data was collected in 4th Quarter 2015
New process began on one patient care unit in February, 2015
Rollout to all patient care areas was completed in July, 2015
Formal mandatory audits ended December, 2015
Random Audit 6 months Later
% of Aspart insulin injections given
within 45 minutes of the glucose test
4th Qtr 2014
Dec 2015
June 2016
35%
79%
69%
The % of timely insulin injections was dropping.
Action was needed to change the direction we were heading.
Lesson Learned
• Process ownership is vital to success
• Ongoing oversight needed for success
• Onboarding insulin education plan for
– New nurses
– Traveling nurses
– Patient Care Techs
• Education Plan needed for Student Nurses
Revised Plan
• Nursing Management would assume role of process owner
of insulin administration process
• Nursing Management would audits
• New nurse orientation was revised to include an e-learning
module that included the process for achieving timely
insulin injections for our patients
• Traveling nurses will have insulin timing education included
in their orientation
• We will meet with faculty from all of our nursing programs
so that the process will be included in their education
modules
Questions