Glycemic Control:The Ongoing Quest

Kathy BowersFerris State University

Inpatient RN Focus Fall 2013

Continuing Nursing Education Credit

• To achieve 2 nursing contact hours, attendee must:– 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.

Criteria/Disclaimers

Objectives

• 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.

At end of offering, participant will be able to:

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

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.

Gluco-lipotoxicity

Acquired factors (obesity)

FFA

T2DM

Insulin deficiency Insulin resistance

Hyperglycemia

Inherited/acquired factors

Production of glucose in the liver

Glucoseuptake

Multiple Contributors

HGP = hepatic glucose production.Defronzo RA. Diabetes. 2009;58(4):773-795.

I n c r e a s e dH G P

H y p e r g l y c e m i a

E T I O L O G Y O F T 2 D M

D E F N 7 5 - 3 / 9 9 D e c r e a s e d G l u c o s eU p t a k e

I m p a i r e d I n s u l i nS e c r e t i o n I n c r e a s e d L i p o l y s i s

HyperglycemiaHyperglycemia

Decreasedincretin effectDecreased insulin

secretion

IncreasedHGP

Islet–A cell

Increasedglucagon secretion

Increasedlipolysis

Increasedglucose reabsorption

Neurotransmitterdysfunction

Decreasedglucose uptake

Primary Types of Diabetes

• 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 1 DM 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 timeCPM Clinical Practice Guidelines: Type 1 Diabetes-Adult, Type 2 Diabetes-Adult. Fall 2010

Complications

• Leading cause of kidney failure, nontraumatic lower-limb 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

• 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%

US Average

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

• 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

DM Risk Factors

Diagnosis

A1C ≥6.5%OR

Fasting plasma glucose (FPG)≥126 mg/dL (7.0 mmol/L)

OR2 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

• Report >200

• A1c next step– 3 month avg. BG control– Normal <5.7%– Pre Diabetes 5.7-6.5%– Diabetes Target <7%

ID the Unknown: Random BG

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/dLOR

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.

RecommendationsRecommendations

• 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.

Prevention/Delay of Type 2 Diabetes

In-Hospital Hyperglycemia

• 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 risko Sepsis

– Delayed wound healing– Skin breakdown– DKA– Coma– Death

Risks

In-Hospital Hyperglycemia

• Most Common – Insulin deficiency – Inappropriate insulin therapy– Infection

• Other – Surgery– Illness– Stress– Medication induced (e.g. steroids)

Causes (Even unrelated to Diabetes)

CPM Clinical Practice Guidelines: Type 1 Diabetes-Adult, Type 2 Diabetes-Adult. Fall 2010

BG Targets

• AC 80-140 mg/dL

• PC blood glucose targets <180 mg/dL

• Random blood glucose targets <180 mg/dL

• 110-140 mg/dL for most patients

Non Critical Care

Critical Care

Targets

200 mg/dL SCIP threshold180 Upper ICU/Non-ICU

Random Target140 Upper Non-ICU Prandial

Target110 Lower ICU Target80 Lower Non-ICU Prandial

Target70 Hypoglycemia40 Severe Hypoglycemia

In-Hospital Hyperglycemia

• Critical Care: IV insulin infusion is preferred – 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 insulin1. 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

Treatment may differ from home

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:

Fruits and Vegetables

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

Protein:

Meats - beef, pork,

poultry, lamb, fish, shellfish

Eggs

Cheese

Tofu

Fats:

Oils

Margarine

Animal fats

Nuts

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 Foods

• 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

Carbohydrate ConsiderationsSo you know…

Diabetes Diets

• 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

Menu/Tray Ticket Updates

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 meal- time 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

• 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

Diabetes DietsInappropriate Diet Orders

MNM DM Appropriate Diet Orders

– 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 Gram Counting

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

• 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

Carbohydrate Choice a.k.a. Consistent Carbohydrate

MNM DM Appropriate Diet Orders

MNM DM Appropriate Diet Orders

• 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

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

• 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

Points to Remember

Module 3:Insulin Safety & Administration

Safety Takes A Vigilant Team

Provider to/from Nurse Orders appropriate Documentation prompt/accurateComplications addressed

Ambassadors to Nurse/PCTBG check before mealsNoting amount eaten on tray slip/to nurse

Nurse to/from PCTHuddle at change of shiftClear expectationsPrompt reporting

BG resultsTray slip/amt eaten to nurse

Nurse/Patient to/from Inpt DM Educator/Dietitian

Advanced educationManagement problem solving

Nurse to NurseChange of shift reportPlan of Care

Nurse to/from PatientEducation early/oftenSymptoms reported/responded toAlert to meal ordering

Glycemic Control Team to TeamTrends identifiedRecommendations made

Communication Critical

MNM Insulin Safety

• 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

Top Issues: 2012-YTD

FlexPen – Single Patient Use!

FlexPen

• 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

Safe Practice Recommendations

FlexPen

• 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

Patient Education Considerations

Insulins & Action Times

Category Insulin Name Onset Peak Duration Maximal Duration

Comments

Long ActingLevemir

Lantus

3-4 hrs

4-6 hrs

Flat Peak

No Peak

Up to 24 hrs

24 hours

24 hours

24 hoursRotate Sites

AnalogCombinations

HumaLOG 75/25

HumuLIN 70/30 & NovoLIN 70/30

5-15 mins

5-15 mins

Broad

Broad

10-16 hours

10-16 hours

Normally dosed before breakfast and

dinner

Intermediate NPH 30-60 mins Broad 10-16 hours

Normally dosed before breakfast and

dinner

Rapid ActingNovoLOG/HumaLOG

Aprida

5-15 mins

5-15 mins

30-90 mins

30-90 mins

< 5 hours

< 5-8 hrs

Short Acting Regular 30-60 mins 2-3 hrs 5-8 hours

U-500 Insulin – HIGH ALERT Medication!

• 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

Humulin Regular U-500 Insulin Considerations

U-500 Insulin – HIGH ALERT Medication!

• 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

U-500 Insulin Safe Practice Procedures

Insulin – Sites of Administration

1. Abdomen 2. Back of upper arm3. Front and upper

side of the thigh4. 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

Fastest to Slowest Absorption Rates:

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)

• 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.

• Give after meals if dietary intake is uncertain

• If <50% of meal eaten, lower dose by 50%.

• Hold if NPO

When to Give:

If Chance Patient Might Not Eat:

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 IntakeNew field on orders for NovoLOG Insulin that isused 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 IntakeComplete 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 long-term.

– 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

• 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!

Critical Care Administration

Module 4:Special Situations

• Continuous SQ Pumps• Pre-Op Patient Management• Dye Procedures • Diabetic Ketoacidosis

Continuous SubcutaneousInsulin Pump (CSII)

CSII - continued…

CSII - continued…

CSII - continued…

CSII

• 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

Process

PreopPRE-PROCEDURE INSTRUCTIONS FOR/ MANAGEMENT OF DIABETES PATIENT

IN OUTPATIENT SETTING (including AM Admit) Protocol 511200

Patient’s Routine Diabetes Medication (See Classifications Below)

Short Acting Insulin* Oral Agent Injectable (Byetta, Symlin)

Intermediate Acting Insulin**

Long Acting Insulin*** Single p.m. dose

Long Acting Insulin*** Single a.m. dose

Long Acting Insulin*** Twice a day dosing

Take half of usual a.m. dose

FBS

If greater than 200mg/dL: Notify

physician (See Abnormal

Result Algorithm)

If less than 70mg/dL:

Hypoglycemia Protocol 999.235

Report if discrepancy

between instructions and

patient compliance

Insulin Pump

Mixed Insulin****

*Short Acting Insulins Humulin R Humalog (Lispro) Novolog (Aspart) Apidra (Glulisine)

**Intermediate Acting Insulins

Humulin N Novolin N NPH

***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

Preprocedure Patient Instructions

Hold a.m. of procedure

If normal 10pm dose 20 units or less: usual p.m. dose

If normal 10pm dose greater than 20 units: half p.m. dose

If normal dose 20 units or less: full 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

If normal dose greater than 20 units: half usual dose

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 pre-procedure medical evaluation.

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

Verify pump is outside operative field and infusing

at basal rate

Nursing Management on Admission

Type 2 DM: Hold insulin (given by nurse on arrival at hospital)

Type 1 DM: Nurse to call anesthesiologist on call/physician in charge as appropriate for instructions

Start time 11 a.m. or

later

Follow above and…

Patient to check Blood Glucose

(BG) upon waking in a.m. and every

4 hours until arrival at hospital

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.

Revised 5/2/08 Dr. Cartwright Reformatted 8/5/09 Diabetes Task Force DRAFT 1/9/12

Insulin Classifications

Type 2 DM: Give half usual a.m. dose as NPH

Pre Procedure

• 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

Potential Dye Issue

Diabetic Ketoacidosis (DKA)

• 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

Emergency Situation

Module 5:Hypoglycemia

Hypoglycemia

• 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

What to Watch For

Treatment Protocol

• 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 sleepOR

• BG <70 (without symptoms)

When to Start

<70

Treatment Protocol

• 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

If patient able to take oral safely:

Treatment Protocol

• 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

If patient unable to take oral safely or NPO:

Treatment Protocol

• Wait 10-15 minutes, recheck--If less than 80, retreat/ repeat as needed

• If pt. has CSII(pump) place in suspend/stop mode notify physician

Evaluate/Subsequent Treatment

<80

Treatment Protocol

• If meal won’t be eaten within 2 hours, have patient eat snack (carbohydrate, NOT fat)

If/when patient able to take oral safely:

Treatment Protocol

• Change in glycemic control plan e.g. insulin orders may be warranted

• Resume CSII at same or different basal rate as ordered

Notify Provider

CALL ALL

Module 6:Diabetes Management Across

the ContinuumHome to Hospital to Discharge

Documentation of Meds by Hx - InsulinTips 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? oro 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 - InsulinExample:

• 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 - InsulinFinished Example:

Order Comments:

Hospital Diabetes ManagementImprovements to Current System:

• CPOM for all Insulin & Diabetes Related Orders

Coming Fall of 2013:

• Updates to Order Form• Wireless Glucometers• Glycemic Control Tab in Power Chart

Changes to Current Order SQ Insulin FormChanges 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 FormBiggest 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 FormWhat 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

• 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)

Data Available on the Glycemic Control Tab

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

• 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

Start on Admission

Resources

• Yale Book

• CPM Guidelines

• CSII website

• ADA

• JCAM 2012

• Medtronic carb counting

Questions?