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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: – – – – 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 – – – – 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 – – – – 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 – – – – – 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 – – – – 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 – – – – 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?