Improving Inpatient Diabetes Care
Nursing Issues
Improving Inpatient Diabetes Care:
Nursing Issues
• Objectives:
 State importance of nursing care in improving
inpatient ...
• The total estimated cost of diabetes in 2007 was $174
billion, with $116 billion attributed to excess medical
expenditur...
Of the $116 billion attributed to excess medical expenditures1
Hospital Inpatient
Days Account for ~50% of Dollars Spent —...
Importance of Nursing Care for
Improving Glycemic Control
• 24 hour coverage by nursing
• Nursing often coordinates, and i...
• Patient not in hospital long
enough to control glucose
adequately
• Lack of guidelines on how to
treat hyperglycemia
• U...
Rapid (lispro, aspart, glulisine)
Hours
Long (glargine)
Short (regular)
Intermediate (NPH)
Long (detemir)
Insulin
Level
0 ...
Insulin Comparison
Insulin Onset Peak Duration
Lispro/aspart/glulisine 5–15 min 1–2 h 2–4 h
Regular 30–60 min 3–4 h 4–8 h
...
Insulin Onset Peak Duration
Lispro 75/25
Aspart Mix
70/30
5–15 min Rapid 1–2 h
Int 4–12 h
14–18h
70/30, 50/50
(N/R)
30–60 ...
Insulin Requirements in
Health & IllnessRelativeproportionofinsulinrequirement(%)*
*Estimations for illustrative
purposes:...
Maintaining Physiologic Insulin
Delivery in the Hospital
Basal insulin
Mealtime
insulin
(bolus)
Supplemental
or “stress”
i...
Normal Endogenous
Insulin Secretion
75/25
SL HS
InsulinEffect
BB BHSSLB
Injection
70/30
1. Adopted insulin curves from: Le...
Selection of Insulin Infusion Protocol
Features of the ideal protocol include that it is:
• Based not only on current bloo...
Selecting the Patient Population to
Start Insulin Infusion Protocol
• Build momentum by starting in areas with
the greates...
Converting from IV Insulin Infusion to
Subcutaneous Insulin in the Hospital
• Calculate the IV basal insulin requirement
...
Subcutaneous Insulin
Therapy in the Hospital
• Standing insulin orders
 Basal, Prandial, Supplemental (correction)
• Insu...
Problem: Managing DM with
Sliding Scale Insulin Only
Problems Effect
Reactive, not proactive Dosing based on inadequacy of...
Point of Care Glucose Testing
and Insulin Administration
• Timing is critical
• Proper timing of glucose testing and insul...
Insulin Administration Timing
• Administer short-acting regular insulin 30
minutes before meals.
• Regular insulin peaks i...
• The Joint Commission considers insulin one
of the 5 highest-risk medicines in the inpatient
setting1
 The consequences ...
• USP’s MEDMARX reporting program uncovered 4764
insulin errors over a 2-year period
 Approximately 6.6% of these caused ...
Barriers to Good Glycemic Control
in the Hospital Setting
Possible Barrier Action
Omission of scheduled
Insulin due to pre...
Possible Barrier Action
Insulin Errors Independent Double
Checks
Standardized Physician
Orders
Education
Barriers to Good ...
Why Are Insulin Errors Common?
• Insulin not held when patient not eating
or becomes NPO
• Incorrectly reading dose
• Ille...
Controlling Hypoglycemia
Hypoglycemia
• Hypoglycemia can be life-threatening
• Common causes of hypoglycemia in the
hospital include:
 Too much in...
What Is Hypoglycemia?
• Blood Glucose less
than or equal to 70
mg/dL in the
hospitalized patient
• Also referred to as
“lo...
Signs and Symptoms of Hypoglycemia
(Blood Glucose <70 mg/dl)
• Tachycardia
• Hunger
• Restlessness
• Weakness /
fatigue
• ...
• Retrospective analysis of response to
insulin-induced hypoglycemia
 Mean BG at the time of dextrose administration for
...
Hypoglycemia Is Serious But Treatable
• Be aware of, or institute a “Hypoglycemia
Order Set”, “Hypoglycemia Protocol”
• Kn...
Counter-Regulatory Hormones
Combating Hypoglycemia
• Glucagon (produced in the alpha cells of the
pancreas)
• Epinephrine/...
Hypoglycemia in Renal/Liver Disease
• Rising serum creatinine
can contribute to
hypoglycemia
• Liver disease can cause a
d...
The 15-15 Rule
• The 15-15 Rule of hypoglycemia
means to give 15 grams of fast-
acting carbohydrate & wait 15
minutes, rec...
Question
• Is it ok to add a
packet of sugar to ½
cup of orange juice
for low blood sugar?
Yes
No
• NO
Initial treatment of
hypoglycemia calls for 15
grams of carbohydrate,
wait for 15 minutes and
then re-check blood
sug...
15 Grams of Carbohydrate Raises
Blood Glucose by 30-50 mg/dL!
• 1 tube oral glucose gel
• 3-4 glucose tablets*
• ½ cup jui...
Treating Hypoglycemia-If The
Patient Can Swallow
• 15 gram glucose tube
or 3-4 glucose tablets*
• 4 oz. Fruit juice
• 8 oz...
Forcing Oral Rx in Unconscious Patient
• This may lead to
aspiration & possibly
death
• Use an IV site
instead to
administ...
Question
• Your patient’s blood glucose
is 29 mg/dl, he is
unconscious and no
glucagon is on the floor but
the patient has...
3. Give 50% Dextrose IV
It is unsafe to put anything
in an unconscious patient’s
mouth.
Answer
Hyperglycemia
• Patients receiving a sliding scale had mean
in-hospital glucose values of 213 mg/dL versus
130 mg/dL (P<0.0001)
• Slidin...
Hyperglycemia
• What is the goal for the bedside nurse?
 Notify the physician when blood glucose
levels are out of contro...
Interventions for Hyperglycemia
• Blood glucose >200 mg/dL
 Call the physician if:
 Blood glucose is >200 mg/dl on admis...
Nursing Role in Good Glycemic Control
• Point of care testing (POCT) for all patients
with diabetes and patients who prese...
• Appropriate timing of point of care testing /
insulin administration and meal delivery
 Document capillary blood glucos...
Blood Glucose Check – Too Early
• The blood glucose is checked at 0610, and
the patient requires regular insulin coverage....
A Typical Meal Tray in the Hospital Will Raise
Blood Glucose by About 200 mg/dL
• Breakfast-2 slices
toast, 1/2 banana, 4
...
It Is Important To Give Insulin As Directed-
However, If A Patient Doesn't Eat A Meal…
• Blood glucose can drop because th...
Question
• If your patient has already started eating a
meal, or has finished a meal, and the glucose
has not been checked...
How does Infection Affect Blood
Glucose Levels?
• Infection
 Increased glucocorticoids from the adrenal glands,
stimulati...
How Do Surgery and Acute Illness
Affect Blood Glucose Levels?
• Surgery and illness
 Increase secretion of counter regula...
What Is the Impact of NPO Status on
the Patient’s Blood Glucose Levels?
• Ideally, patients will have surgery early in
the...
NPO Patients
• If the patient is made NPO
• Management is different for type 1 and type 2
 type 1 patients still need bas...
• If the patient is made NPO:
Give ½ of the basal insulin dose and
hold the mealtime insulin, and continue
the correction ...
What Is the Impact of Tube Feedings
on Blood Glucose Levels?
• Patients on tube feedings will usually receive a
continuous...
What Is the Impact of Total Parenteral
Nutrition (TPN) on Blood Glucose?
• Patients on total parenteral nutrition (TPN) ma...
Impact of Medications
on Blood Glucose Levels
• Medications used for the treatment of
co-morbid conditions can cause hyper...
Steroids
• Stimulate hepatic glucose production
and inhibit peripheral glucose uptake
• Dexamethasone: Half life 48 hrs
• ...
Nursing Role in Good Glycemic Control
• Appropriate timing of PCT/ Insulin
administration and meal delivery
 Document FS ...
Nursing Role in Good Glycemic Control
• Appropriate patient hand off when transferring
patient to another area of the hosp...
Nursing is Critical
Throughout Hospitalization
• Assessing patients’ self-management capabilities
• Providing support for patients in self-management
activities
• Involv...
• Patients with newly diagnosed diabetes or educational
deficits have at least the following educational components
reflec...
Admission Diabetes Assessment
• Documentation of type, duration of diabetes,
and current treatment
• Assessment of patient...
Health Literacy
• Not the same as literacy
• More than 40% of patients with chronic illnesses
are functionally illiterate
...
Addressing Health Literacy
• Use graphics/pictures
• Use variety of media
• Use “teach back” method to assess understandin...
Health Numeracy
• Difficulty adding and subtracting
• Effects in diabetes
 Carbohydrate counting
 Adding correction insu...
Patient / Family Education
• Review/evaluate
insulin injection
technique
• New to insulin
 Instruct ASAP
 Give own insul...
Nursing Role in Good Glycemic Control
• Appropriate patient hand off when transferring
patient to another area of the hosp...
• Appropriate timing of PCT/ Insulin administration
and Meal delivery
• Recognition of hyper/hypoglycemia and
appropriate ...
Transition to Discharge
Nursing Role in Good Glycemic Control
Ensure pt has had Survival Skills
Self-management Education
• Use of personal glucos...
Connecting Inpatient Care to
Outpatient Support
• Multidisciplinary team: bedside nurse,
clinical pharmacist, registered d...
Transition to Discharge
• Does patient have a glucose monitor for home
use? If not call case manager/ D/C planner or
Diabe...
Sources Inpt RNs Used to Learn
About New Meds
Derr, et al Diabetes Spectrum, 20: 177-185, 2007
To Enhance Nurses’ Knowledge
• Inservices to cover all shifts
• Web-based inservices/journal clubs
 Can be viewed at oppo...
Intake and
Identification
Admission
Data Base
Multidisciplinary
Team Referrals
Focused Clinical
Assessment
Focused Bedside...
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  • This slide demonstrates in graphic fashion the peak and duration of action of the various insulin formulations now available. Note that pre-mixed insulin products (i.e., 70/30, etc.) are not shown.
  • People who take 2 injections of split-mixed or pre-mixed insulin will typically take approximately 2/3 of the total daily dose as the morning injection and 1/3 of the total daily dose as the afternoon or evening injection
    Premixed 75/25 and 70/30 insulin are often taken twice daily
    The insulin levels that result from this method, as shown in these figures, do not match the normal endogenous secretory pattern, shown in the shaded background.
    Type 2 diabetes patients who have substantial endogenous insulin fare better than patients with type 1 diabetes, but type 2 diabetes patients may experience late morning or nocturnal hypoglycemia due to excessive levels of insulin at these time
  • [annotation: Stotland/pp.43/Table2]
  • [annotation: Stotland/pp.43/Table2]
  • Should examples follow or precede this slide?
  • presentation

    1. 1. Improving Inpatient Diabetes Care Nursing Issues
    2. 2. Improving Inpatient Diabetes Care: Nursing Issues • Objectives:  State importance of nursing care in improving inpatient diabetes care  Identify strategies to improve glycemic control in hospitalized patients with diabetes  Differentiate among basal, prandial and correction insulin  State importance of hypoglycemia protocols
    3. 3. • The total estimated cost of diabetes in 2007 was $174 billion, with $116 billion attributed to excess medical expenditures1  The largest component of medical expenditures attributed to diabetes was hospital inpatient care (50% of total cost) • Diabetes ranked #2, after circulatory diseases, as a hospital discharge diagnosis in 20052  Diabetes made up 11% of all first-listed diagnosis ICD-9-CM Codes  Discharges with diabetes as a first-listed diagnosis accounted for about 2.8 million days of hospital stay 1. American Diabetes Association. Economic Costs of Diabetes in the U.S. in 2007. Diabetes Care 2008;31:1–20. 2. http://www.cdc.gov/diabetes/statistics/hosp/adulttable1.htm Accessed January 21, 2008. Impact of Diabetes on Hospitals is Staggering
    4. 4. Of the $116 billion attributed to excess medical expenditures1 Hospital Inpatient Days Account for ~50% of Dollars Spent — More than $58 Billion Inpatient Hospital Costs Account for Greatest Proportion of Health Care Expenditures for Patients with Diabetes American Diabetes Association. Economic Costs of Diabetes in the U.S. in 2007. Diabetes Care 2008;31:1–20. $3.3 B Hospital Outpatient $2.2 B Emergency Department $0.1 B Ambulance $13.9 B Nursing Home $10.0 B Physician Office $3.9 B Home Health Care Units $0.5 B Hospice $5.5 B Outpatient Medication $5.0 B Oral agents $7.0 B Insulin and Delivery Supplies Annual Costs Due to Diabetes Hospital Inpatient $58.3 Billion
    5. 5. Importance of Nursing Care for Improving Glycemic Control • 24 hour coverage by nursing • Nursing often coordinates, and is aware of, the multiple services required by patient  e.g, travel off unit, e.g. physical therapy, X-ray  Amount of food eaten (carbs)  Patient’s day to day concerns  Order changes (by various providers)
    6. 6. • Patient not in hospital long enough to control glucose adequately • Lack of guidelines on how to treat hyperglycemia • Unpredictable timing of patient procedures • Risk of causing patient hypoglycemia • Unpredictable changes in patient diet and mealtimes • Preferring to defer management to outpatient care or to another specialty • Knowing best options to treat hyperglycemia • Knowing how and when to start insulin • Knowing what insulin type or regimen works best • Knowing how to adjust insulin Perceived Barriers to Management of Inpatient Hyperglycemia
    7. 7. Rapid (lispro, aspart, glulisine) Hours Long (glargine) Short (regular) Intermediate (NPH) Long (detemir) Insulin Level 0 2 4 6 8 10 12 14 16 18 20 22 24 Pharmacokinetics of Insulin Products Adapted from Hirsch I. N Engl J Med. 2005;352:174–183.
    8. 8. Insulin Comparison Insulin Onset Peak Duration Lispro/aspart/glulisine 5–15 min 1–2 h 2–4 h Regular 30–60 min 3–4 h 4–8 h NPH (N) 1–2 h 4–12 h 14–18 h Detemir/Glargine 1–2 h Relatively Peakless Up to 24 h
    9. 9. Insulin Onset Peak Duration Lispro 75/25 Aspart Mix 70/30 5–15 min Rapid 1–2 h Int 4–12 h 14–18h 70/30, 50/50 (N/R) 30–60 min 3–12 h 14–18h Insulin Comparison
    10. 10. Insulin Requirements in Health & IllnessRelativeproportionofinsulinrequirement(%)* *Estimations for illustrative purposes: requirements may vary widely. Diabetes Care 27:553-91, 2004. Sick/Eating Healthy Sick/ NPO Illness-Related 0 20 40 60 80 100 120 140 Correction Nutritional Prandial Basal
    11. 11. Maintaining Physiologic Insulin Delivery in the Hospital Basal insulin Mealtime insulin (bolus) Supplemental or “stress” insulin
    12. 12. Normal Endogenous Insulin Secretion 75/25 SL HS InsulinEffect BB BHSSLB Injection 70/30 1. Adopted insulin curves from: Lepore M, et al. Diabetes. 2000;49:2142-2148. 2. Pampanelli S, et al. Diabetes Care. 1995;18:1452-1459 Twice-Daily Split-Mixed Regimens InsulinEffect
    13. 13. Selection of Insulin Infusion Protocol Features of the ideal protocol include that it is: • Based not only on current blood glucose, but also on the rate of change, and insulin sensitivity of the patient. • Easy to implement and use • Clear and has specific directions for titration • Specific as to directions for blood glucose monitoring • Clear as to definition of hypoglycemia and treatment • Implemented by nursing Use a validated protocol!
    14. 14. Selecting the Patient Population to Start Insulin Infusion Protocol • Build momentum by starting in areas with the greatest support • Select a nursing unit/ward as pilot • Pharmacy can assist with safety concerns  Educate about short duration of effect with IV insulin (minutes vs. hours with subcutaneous insulin)  Appropriate monitoring  Revision of policies and procedures
    15. 15. Converting from IV Insulin Infusion to Subcutaneous Insulin in the Hospital • Calculate the IV basal insulin requirement  Insulin delivered overnight for 4 hours  Multiply by 6 = 24 hour insulin requirement  Take 50-80% of this number to determine the basal dose and give 2-4 hrs prior to d/c of IV insulin infusion  Example: 10 units from 1 am to 5 am  10x6=60 total daily units  30-48 units as basal insulin  IV infusion ordered to be d/c’d at 10 am, basal insulin given at 7 am
    16. 16. Subcutaneous Insulin Therapy in the Hospital • Standing insulin orders  Basal, Prandial, Supplemental (correction) • Insulin needs assessed in the context of concurrent stress/medications affecting glucose • Do not omit doses for good control or mild hypoglycemia • Review glucose results and adjust insulin daily • Review chart for unusual circumstances  Missed meals, hypoglycemia treatment, late insulin
    17. 17. Problem: Managing DM with Sliding Scale Insulin Only Problems Effect Reactive, not proactive Dosing based on inadequacy of previous dose Goal is hyperglycemia Starts at 200mg/dl Does not account for previous regimen “one size fits all” Rarely reevaluated Pt’s glucose control is rarely reevaluated Little to no clinical thinking Without clinical basis, endpoints, lack critical thinking No basal insulin Fasting, postprandial, nocturnal, and inter-meal glucose control
    18. 18. Point of Care Glucose Testing and Insulin Administration • Timing is critical • Proper timing of glucose testing and insulin administration can reduce the risk of hypo/hyper glycemia • POC testing should be done in relation to type of prandial insulin patient is using
    19. 19. Insulin Administration Timing • Administer short-acting regular insulin 30 minutes before meals. • Regular insulin peaks in 2-4 hours • Administer rapid-acting analog insulin 15 minutes before meals. • Rapid-acting insulin analogs peak in 60-90 minutes • If insulin is administered too early, its action will not “cover” the prandial elevations in blood glucose and may even cause premeal hypoglycemia
    20. 20. • The Joint Commission considers insulin one of the 5 highest-risk medicines in the inpatient setting1  The consequences of errors with insulin therapy can be catastrophic • Insulin is consistently implicated in causing severe adverse events in hospitals through reporting systems maintained by USP and ISMP2 Insulin Therapy: High Risk for Errors USP = US Pharmacopeia; ISMP = Institute for Safe Medication Practices. 1. Int J Qual Health Care. 2001;13(4)339–340. 2. ASHP; HAP. http://www.ashp.org/s_ashp/docs/files/Safe_Use_of_Insulin.pdf. Accessed January 29, 2008.
    21. 21. • USP’s MEDMARX reporting program uncovered 4764 insulin errors over a 2-year period  Approximately 6.6% of these caused harm to the patient  Average harm threshold for error reports submitted to MEDMARX is about 2.8%  Insulin may be twice as likely to result in harm as other medications Omission errors and improper dose/quantity were the 2 most frequently reported types of medication errors associated with insulin USP. http://www.usp.org/pdf/EN/patientSafety/capsLink2003-07-01.pdf. Accessed December 8, 2007. Insulin Errors Twice as Likely to Cause Harm Than Other Medication Errors
    22. 22. Barriers to Good Glycemic Control in the Hospital Setting Possible Barrier Action Omission of scheduled Insulin due to previous low blood sugar or “normal” blood sugar Nursing education about insulin physiology and glucose dynamics. Do not hold insulin just because blood glucose is under good control. Do not omit the basal insulin just because the patient is hypoglycemic. Do not hold the correction dose if the patient does not eat, only hold the meal dose.
    23. 23. Possible Barrier Action Insulin Errors Independent Double Checks Standardized Physician Orders Education Barriers to Good Glycemic Control in the Hospital Setting
    24. 24. Why Are Insulin Errors Common? • Insulin not held when patient not eating or becomes NPO • Incorrectly reading dose • Illegible handwriting  ‘u’ often mistaken for ‘0’ and 10x ordered dose given  e.g.. 4 ‘IU’ mistaken for 41 units • Dispensing Regular U500 insulin • Insulin names confusing  Humulin vs. Humalog  Lantus vs. Lispro  Novolin vs. Novolog • Sheer Volume of Insulin Injections
    25. 25. Controlling Hypoglycemia
    26. 26. Hypoglycemia • Hypoglycemia can be life-threatening • Common causes of hypoglycemia in the hospital include:  Too much insulin or insulin given out of sync with meals  Inadequate food intake, vomiting  Oral hypoglycemic agents, with or without insulin, continued with changes in eating status (e.g. NPO)  Unexpected transport off unit after insulin given
    27. 27. What Is Hypoglycemia? • Blood Glucose less than or equal to 70 mg/dL in the hospitalized patient • Also referred to as “low blood sugar” • Classified as mild, moderate, or severe
    28. 28. Signs and Symptoms of Hypoglycemia (Blood Glucose <70 mg/dl) • Tachycardia • Hunger • Restlessness • Weakness / fatigue • Diaphoresis • Pallor • Shakiness • Irritable • Anxious • Lightheaded • Change in mental status (i.e. confused) • Impaired vision/dilated pupils • Headache
    29. 29. • Retrospective analysis of response to insulin-induced hypoglycemia  Mean BG at the time of dextrose administration for hypoglycemia was 52 mg/dL (range 31–68)  While insulin dose was held at the time of the hypoglycemic episode in all 52 patients, changes were subsequently made in the treatment of only 40% of patients Poor Provider Response to Insulin-Induced Hypoglycemia in Hospitalized Patients Garg R, et al. J Hosp Med. 2007;2:258–60.
    30. 30. Hypoglycemia Is Serious But Treatable • Be aware of, or institute a “Hypoglycemia Order Set”, “Hypoglycemia Protocol” • Know the “peak time” of the different types of insulin • Remember that more activity (energy output) or less carbohydrate (energy intake) can cause hypoglycemia
    31. 31. Counter-Regulatory Hormones Combating Hypoglycemia • Glucagon (produced in the alpha cells of the pancreas) • Epinephrine/epinephrine (responsible for many of the autonomic s/s of hypoglycemia) • Growth hormone • Cortisol • Counter-regulatory hormones increase blood glucose during stress, and in the early AM (circadian rhythm). • Patients with type 1 DM have less counter-regulatory glucagon hormone reserves (w/i 2-5 years of diagnosis) than type 2 DM
    32. 32. Hypoglycemia in Renal/Liver Disease • Rising serum creatinine can contribute to hypoglycemia • Liver disease can cause a depletion of glucose reserves for treatment of hypoglycemia
    33. 33. The 15-15 Rule • The 15-15 Rule of hypoglycemia means to give 15 grams of fast- acting carbohydrate & wait 15 minutes, recheck a blood glucose & then give another dose of 15 grams of fast-acting carbohydrate, if necessary
    34. 34. Question • Is it ok to add a packet of sugar to ½ cup of orange juice for low blood sugar? Yes No
    35. 35. • NO Initial treatment of hypoglycemia calls for 15 grams of carbohydrate, wait for 15 minutes and then re-check blood sugar. Do not over treat. Answer
    36. 36. 15 Grams of Carbohydrate Raises Blood Glucose by 30-50 mg/dL! • 1 tube oral glucose gel • 3-4 glucose tablets* • ½ cup juice • 1 tablespoon sugar, honey or jelly • 8 oz. Milk *Glucose tablets may contain 4 or 5 Gm of glucose
    37. 37. Treating Hypoglycemia-If The Patient Can Swallow • 15 gram glucose tube or 3-4 glucose tablets* • 4 oz. Fruit juice • 8 oz. Milk *Glucose tablets may contain 4 or 5 Gm of glucose
    38. 38. Forcing Oral Rx in Unconscious Patient • This may lead to aspiration & possibly death • Use an IV site instead to administer Dextrose • OR • Administer IM or SC glucagon
    39. 39. Question • Your patient’s blood glucose is 29 mg/dl, he is unconscious and no glucagon is on the floor but the patient has an IV site. Do you: 1. Squirt glucose gel in his cheek 2. Send someone for glucagon 3. Give 50% Dextrose
    40. 40. 3. Give 50% Dextrose IV It is unsafe to put anything in an unconscious patient’s mouth. Answer
    41. 41. Hyperglycemia
    42. 42. • Patients receiving a sliding scale had mean in-hospital glucose values of 213 mg/dL versus 130 mg/dL (P<0.0001) • Sliding Scale Insulin was associated with higher odds ratios of the following outcomes:  Cardiovascular complications or death (OR=1.86; 95% CI 0.99–3.49)  Sepsis or ICU admission (OR=4.98; 95% CI 2.38–10.42) Becker T, et al. Diabetes Res Clin Pract. 2007;78:392–7. Sliding Scale Insulin is Associated with Higher Glucose Levels and Poorer Clinical Outcomes
    43. 43. Hyperglycemia • What is the goal for the bedside nurse?  Notify the physician when blood glucose levels are out of control  Implement the orders and notify the physician when indicated to avoid hyperglycemia and hypoglycemia
    44. 44. Interventions for Hyperglycemia • Blood glucose >200 mg/dL  Call the physician if:  Blood glucose is >200 mg/dl on admission  The first time BG is 200 mg/dl if not previously reported  Written in the physician orders, “call for blood sugar remains out of control despite therapy or per orders”  Administer insulin per physician’s order  Hydrate the patient as indicated by physician’s order
    45. 45. Nursing Role in Good Glycemic Control • Point of care testing (POCT) for all patients with diabetes and patients who present with hyperglycemia on admission • Special situations that cause hyperglycemia – steroids, immunosuppressants (cyclosporin) atypical anti-psychotics • Enteral nutrition or TPN • Start POCT without an order – need guideline for care or policy
    46. 46. • Appropriate timing of point of care testing / insulin administration and meal delivery  Document capillary blood glucose and the time  Document Insulin dose and the time given  Document % of the carbohydrate eaten Nursing Role in Good Glycemic Control
    47. 47. Blood Glucose Check – Too Early • The blood glucose is checked at 0610, and the patient requires regular insulin coverage. The insulin is given at 0620. Breakfast arrives at 0800 • This could potentially lead to hypoglycemia • Ideally the regular insulin should be given ½ hour before or if needs be-with the meal but not greater than ½ hour before the meal
    48. 48. A Typical Meal Tray in the Hospital Will Raise Blood Glucose by About 200 mg/dL • Breakfast-2 slices toast, 1/2 banana, 4 oz. Juice, eggs & sausage • Lunch-sandwich, 8 oz. Milk, 1 small cookie • Dinner-roll, 1/4 cup fruit, 2/3 cup rice, 8 oz. Milk, Pork-chop
    49. 49. It Is Important To Give Insulin As Directed- However, If A Patient Doesn't Eat A Meal… • Blood glucose can drop because the carbohydrates predicted did not match up to carbohydrates ingested
    50. 50. Question • If your patient has already started eating a meal, or has finished a meal, and the glucose has not been checked, what should you do? • If it has been within 15 minutes, test the blood glucose and correct as usual • If it has been more than 15 minutes, check blood glucose and contact the physician
    51. 51. How does Infection Affect Blood Glucose Levels? • Infection  Increased glucocorticoids from the adrenal glands, stimulating hepatic glucose production, causing hyperglycemia  Epinephrine and norepinephrine (catecholamines) increase, causing increased hepatic glycogen breakdown into glucose, causing hyperglycemia
    52. 52. How Do Surgery and Acute Illness Affect Blood Glucose Levels? • Surgery and illness  Increase secretion of counter regulatory hormones, including cortisol, catecholamines, growth hormone, and glucagon  These hormones cause hyperglycemia by:  Inhibiting glucose uptake by the muscle tissue  Suppressing insulin release  Increasing breakdown of glycogen by the liver  Increasing peripheral insulin resistance
    53. 53. What Is the Impact of NPO Status on the Patient’s Blood Glucose Levels? • Ideally, patients will have surgery early in the morning to avoid a prolonged length of time being NPO • NPO patients need regular blood glucose monitoring (q 4-6 hours) and may need IV fluid • NPO patients on oral diabetic medications with long duration are at risk for hypoglycemia
    54. 54. NPO Patients • If the patient is made NPO • Management is different for type 1 and type 2  type 1 patients still need basal insulin • Transports with insulin on board • Advocate for early test procedures so pts do not miss too many meals • Solution – use insulin analogs for basal/bolus
    55. 55. • If the patient is made NPO: Give ½ of the basal insulin dose and hold the mealtime insulin, and continue the correction dose Monitor BG Q 6 hours and give corrective insulin as needed Resume the previous regimen once the patient is eating again NPO Patients
    56. 56. What Is the Impact of Tube Feedings on Blood Glucose Levels? • Patients on tube feedings will usually receive a continuous flow of carbohydrates via their feeding • Blood glucose monitoring (usually q 4 hrs or Q 6 hrs) and scheduled dose of insulin plus corrections are needed • Interruption of feeding can cause hypoglycemia and IV dextrose may be needed while the feeding is off Notify physician for IV dextrose and adjustment of insulin orders when there is interruption or change in feeding rate
    57. 57. What Is the Impact of Total Parenteral Nutrition (TPN) on Blood Glucose? • Patients on total parenteral nutrition (TPN) may have insulin in the TPN or may be on SC insulin • Blood glucose monitoring q 4-6 hrs is needed • Interruption of TPN can cause hypoglycemia and initiation of IV dextrose may be needed Notify physician for IV dextrose and adjustment of insulin orders when there is interruption or change in TPN
    58. 58. Impact of Medications on Blood Glucose Levels • Medications used for the treatment of co-morbid conditions can cause hyperglycemia  Corticosteroids (i.e., Solumedrol, Solucortef, Prednisone, Decadron) can increase glucose production by the liver and increase insulin resistance  Reduction or discontinuation of the steroid can cause hypoglycemia Notify physician for adjustment of insulin orders when there is a change in steroid dose
    59. 59. Steroids • Stimulate hepatic glucose production and inhibit peripheral glucose uptake • Dexamethasone: Half life 48 hrs • AM Prednisone:  Effect usually seen post meals  Peak effect on glycemia 2 PM to 8 PM Leak, A, et al. Cl J Oncology Nurs. 13:205-10, 2009
    60. 60. Nursing Role in Good Glycemic Control • Appropriate timing of PCT/ Insulin administration and meal delivery  Document FS blood glucose and the time  Document Insulin dose and the time given  Document % of the carbohydrate eaten • When to hold insulin? Do not hold insulin just because blood glucose is under good control!
    61. 61. Nursing Role in Good Glycemic Control • Appropriate patient hand off when transferring patient to another area of the hospital  Meal plan order  Last capillary glucose level  Insulin dose and last insulin given  Patient teaching done and patient’s response  Identified further educational needs of patient/family  Transport sheet
    62. 62. Nursing is Critical Throughout Hospitalization
    63. 63. • Assessing patients’ self-management capabilities • Providing support for patients in self-management activities • Involving patients in developing the plan of care • Educating patients in the theory and skills necessary to manage their disease(s) • Recognizing and supporting self-management efforts Joint Commission standards mirror those of diabetes organizations with regard to patient self-management. The Joint Commission. Disease-Specific Care Certification Guide, 1–30. The Standards: Supporting Patient Self-Management
    64. 64. • Patients with newly diagnosed diabetes or educational deficits have at least the following educational components reflected in the plan of care  Medication management, including how to administer insulin (when appropriate) and potential medication interactions  Nutritional management, including the role of carbohydrate intake in blood glucose management  Exercise  Signs and symptoms of hyperglycemia and hypoglycemia  Treatment of hyperglycemia and hypoglycemia  Importance of blood glucose monitoring and how to obtain a blood glucose meter  Instruction on use of blood glucose meter, if available  Sick day guidelines  Information for who to contact in case of emergency or for more information  Plan for postdischarge education or self-management support The Joint Commission. http://www.jointcommission.org/NR/rdonlyres/1F9B67 C2–72A6–4DC3–A047– 15BEB394FE3C/0/Diabetes_Addendum.pdf. Accessed February 4, 2008. Joint Commission’s Certificate: Self-Management Education
    65. 65. Admission Diabetes Assessment • Documentation of type, duration of diabetes, and current treatment • Assessment of patient’s need for diabetes and nutrition education • Determination of need for meter teaching • Assessment of patient’s “competency” to perform SMBG • Assessment of patient’s “competency” to manage diabetes medications and/or insulin
    66. 66. Health Literacy • Not the same as literacy • More than 40% of patients with chronic illnesses are functionally illiterate • Almost a quarter of all adult Americans read at or below a 5th grade level, while medical information leaflets are typically written at a 10th grade reading level or above • An estimated three out of four patients discard the medication leaflet • Low health literacy skills have increased our annual health care expenditures by $73 billion
    67. 67. Addressing Health Literacy • Use graphics/pictures • Use variety of media • Use “teach back” method to assess understanding • Focus education materials on pt action and motivation • Check for pt understanding • Implement f/u phone calls to reinforce instructions Chugh A, et al. Front Health Serv Manage, 25:11-32, 2009
    68. 68. Health Numeracy • Difficulty adding and subtracting • Effects in diabetes  Carbohydrate counting  Adding correction insulin to prandial insulin  Recommended example:  If your blood sugar is 80 to150, take 10 units ____ insulin  If your blood sugar is 151 to 200, take 12 units____ insulin  If your blood sugar is 201 to 250, take 15 units____ insulin
    69. 69. Patient / Family Education • Review/evaluate insulin injection technique • New to insulin  Instruct ASAP  Give own insulin as input  Use handouts
    70. 70. Nursing Role in Good Glycemic Control • Appropriate patient hand off when transferring patient to another area of the hospital  Meal plan order  Last capillary glucose level  Insulin dose and last insulin given  Patient teaching done and patient’s response  Identified further educational needs of patient/family  Transport sheet
    71. 71. • Appropriate timing of PCT/ Insulin administration and Meal delivery • Recognition of hyper/hypoglycemia and appropriate management • Know when to hold insulin • Documentation of PCT and insulin administration • What to do when TPN or tube feeding is interrupted • Appropriate patient hand off • Patient self-management education • Transition to Discharge Nursing Role in Good Glycemic Control
    72. 72. Transition to Discharge
    73. 73. Nursing Role in Good Glycemic Control Ensure pt has had Survival Skills Self-management Education • Use of personal glucose monitor • Rudiments of meal plan (effect of CHO) • Medications, how and when to administer, side effects • Symptoms and treatment of hypo/hyperglycemia • When and whom to contact with problems (be sure patient has a name and phone number). • Additional education/resources JCAHO, Disease Specific Care-Inpatient Diabetes Certification, 12/09
    74. 74. Connecting Inpatient Care to Outpatient Support • Multidisciplinary team: bedside nurse, clinical pharmacist, registered dietitian, case manager • High-risk patients identified at admission • Bedside nurse does assessment using Admission Database form and adds 5 questions related to diabetes. • If need identified, bedside nurse contacts appropriate team member Pollom RK et al. Crit Care Nurs Q.27:185-8, 2004
    75. 75. Transition to Discharge • Does patient have a glucose monitor for home use? If not call case manager/ D/C planner or Diabetes Care Center (DCC) to arrange for one • Does patient know how to inject insulin and how to prevent and to treat hypoglycemia? • Is patient clear about the diabetes therapy after D/C? • Does patient need more diabetes education? Refer to DCC for further education • Does patient have appropriate outpatient F/U appointment with primary care or specialist?
    76. 76. Sources Inpt RNs Used to Learn About New Meds Derr, et al Diabetes Spectrum, 20: 177-185, 2007
    77. 77. To Enhance Nurses’ Knowledge • Inservices to cover all shifts • Web-based inservices/journal clubs  Can be viewed at opportune times  Offer CEs • Nursing champion • Diabetes “resource nurse” on each unit  Receive extra education re diabetes  Used as “rung” on clinical ladder
    78. 78. Intake and Identification Admission Data Base Multidisciplinary Team Referrals Focused Clinical Assessment Focused Bedside Teaching/Interventions Discharge Summary and Documentation Of Met Needs Appropriate Inpatient/Outpatient Referrals and Consultations Multidisciplinary Involvement and Coordination is Required Connecting Inpatient Care to Outpatient Support: Circle of Care Pollom RK, Pollom RD. Crit Care Nurse Q. 2004;27(2):185–188.
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