Insulin protocol

Question 1

What is stress hyperglycemia?

Answer 1

When blood sugar occurs during acute illness in pt w/ previously normal glucose tolerance.

Question 2

What adverse effects of hyperglycemia occur in hospitalized pt, irrespective of its cause?

Answer 2

• Infection, poor wound healing, decreased WBC fxn
• Delayed gastric emptying
• Volume and electrolyte disturbances
• Delayed hospital d/c, increased morbidity and mortality in pt w/ acute MI, CVA, CABG

Question 3

What are continuous insulin infusion (insulin drip) recommendations based on?

Answer 3

• immediate blood glucose results
• rate of change in the blood glucose since the last measurement

Question 4

Risks of using IV insulin

Answer 4

• Hypoglycemia (BG < 70)
  
  • counter-regulatory hormones can be harmful
• Severe hypoglycemia (BG <50)
  
  • transient cognitive deficits, stroke, MI, death
• DKA
  
  • if drip turned off with no alternative basal insulin source in a type 1 diabetic

Question 5

If a pt with type 1 DM is NPO, what are the insulin needs?

Answer 5

• Pt needs basal insulin at all times or is at risk of DKA.
• Should have insulin drip or start pt on glargine

Question 6

UCSD units that use the “insulin computer protocol”

Answer 6

• ICU
• PCU
• ED
• OR
• Reproductive medicine

Question 7

Physician responsibility

Answer 7

• Order insulin computer protocol in EPIC
• consult regarding tx orders and clinical decisions:
  
  • if computer’s calculated rate doesn’t make clinical sense (very high or low)
  • what to do if pt is off the insulin drip for an extended time period
  • carbohydrate mismatch or change in the pt’s oral, enteral, or IV intake or nutrition (i.e. pt becomes NPO or nutrition stopped for any reason)

Question 8

Pharmacist Responsibility

Answer 8

• Approves and verifies the protocl per MD medication orders
• resource for nurses and physicians
• May “reset” the computer protocol when clinically indicated:
  
  • when pt is off insulin drip for 8hrs or more (e.g. NPO for procedure)
  • when pt source of nutrition is interupted
  • pt fails to transition off insulin drip and needs to be restarted
  • when the pt’s clinical status dramatically changes
  • when questions arise based on the pt’s clinical condition

Question 9

Nursing responsibility

Answer 9

• Log-in to web based calculator
  
  • select pt unit and patient
  • enter BG levels as directed and add indicated comments
• enter all POC BG values in calculator (even when drip is on hold)
  
  • computer protocol will give recommendations for adjustment of the insulin rate and recommendations to give a supplemental bolus of insulin (on initiation only)

Question 10

Q1h vs Q2h blood glucose check

for continuous insulin drips

Answer 10

• EVERY HOUR
  
  • Blood glucose POC is checked and insulin calculator used
  • Anytime BG is out of range when checking q2h, must resume hourly testing until stable for another 3 consecutive draws
• EVERY 2 HOURS (never more)
  
  • ​If the hourly checks are within target range for 3 consecutive draws, the RN may modify the POC BG to q2h

Question 11

What do you do if the pt POC blood glucose is <70 mg/dL?

Answer 11

• Stop the insulin infusion
  
  • ​Tx the low glucose according to hypoglycemia protocol
    
    • ​located where?: Medication resources and in the eMAR
• If the insulin computer protocol ever recommends holding the insulin drip, call the pharmacist to discuss further.
  
  • usually there has been an interuption in source of glucose (TPN, TF, IVFs, IV drip, etc) or the pt’s insulin sensitivity is improving and the ISC needs to be reset
• Recheck BG q15min until BG is >80 twice before restarting the insulin drip
  
  • then infuse per computer protocol
    
    • If the first repeat is BG >90 the calculator will recommend restarting the drip, but UCSD policy states >80 twice, so select “I DO NOT AGREE” and then Yes (to are you sure?).
    • When >80 twice, it will give adjusting insulin rate

Question 12

UCSD hypoglycemia protocol

treatment for Consicous pt able to swallow and take PO?

Answer 12

1. Treatment
   
   • (consicious): give fast acting carbohydrate
     
     • ​​4 glucose tablets (16g) or
     • 4oz juice or
     • 8oz skim milk or
     • 1 tube glucose gel
   • (unconscious): give 25ml (12.5g) of D50 IV over 5 minutes
     
     • ​or if no IV access, give 1mg glucagon IM (DO NOT REPEAT)
       
       • ​turn pt on side, may induce vomiting
     • start IV in case need another dose
2. Retest: within 15-30 min from initial glucose test
   
   • repeat tx if BG < 80, and retest within 30min
   • continue until BG > 80 twice
3. Assess: possible causes and need for consult
   
   • most commonly: interruption in food, tube feeding or IV dextrose and decreased steroids no matched with decreased insulin
   • Need medicine or endocrine consult for recurring hypoglycemia?
   • Need to stop oral agent or reduce insulin?
4. Notify: MD of the event
   
   • SBAR (include vitals, symptoms, time of last nutritional intake, time/dose of glucose lowering agents, response to therapy)
   • Ask for change in regiment
5. Document:
   
   • event
   • time of glucose checks
   • s/s
   • treatment
   • resolution assessment
   • correspondence with MD
   • changes in therapy

Question 13

Example of hypoglycemia event documentation

Answer 13

• 11:00am- Pt shaky and diaphoretic. BG=46
• 11:03am- Pt given 4 glucose tablets
• 11:25am- BG=74. Pt given 8 oz milk. Lunch served.
• 11:55am- BG=128
• 12.20pm- BG=169. Pt denies complaints. Pt states he feels “Fine”.
• 12:40pm- Dr. Smith notified of pt’s hypoglycemia, tx, and current status. Insulin dose changed per MD.

Question 14

Nursing documentation

Answer 14

• enter POC blood glucose results into Insulin Computer Calculator
• Chart insulin infusion rates and any bolus doses in the EPIC eMAR
• Enter comment directly in glucose meter for critical values
• Document detail of hypoglycemia even in EPIC doc flow sheet

Question 15

“Nutrition On Hold Unexpectedly Guideline”

• Needed when?
• Found where?

Answer 15

• Interruption in nutrition:
  
  • NPO status for procedure
  • tube feeding is stopped
  • feeding tube is inadvertently pulled out
  • TPN is held or stopped for any reason
• algorithm guideline found in Medication resources

Question 16

When to call pharmacy

Answer 16

• During periods of unscheduled computer downtime, the RN will alert the MD of record of the downtime and contact the clinical pharmacist for dosage recommendations
• any interruption in the pt’s source of nutrition (TPN, TF, IVFs with dextrose, oral)
• If the RN does not agree with the computer recommendation
• Any deviation from computer recommendation
• OR ANY QUESTIONS AT ALL

Question 17

Reasons to Notify Physician/Provider

Answer 17

• Any interruption in the pt’s source of nutrition (TPN, TF, IVFs with dextrose, oral)
• The insulin computer calculator recommendations don’t make sense
• Decline in clinical status
• Computers are down
• Patient is refusing point of care testing