INPATIENT BLOOD GLUCOSE CONTROL Policies Procedures and Protocols

INPATIENT BLOOD GLUCOSE CONTROL: Policies, Procedures, and Protocols A learning module for UNIT SECRETARIES at Saint Joseph Health System Developed by: Dana Graves RN, MSN, CDE Diabetes Clinical Nurse Specialist December 2008 revised

INPATIENT BLOOD GLUCOSE CONTROL: Policies, Procedures, and Protocols ¨ 1. 2. This learning module is required for orientation to Diabetes Care issues and blood glucose control here at Saint Joseph Health System. This can also be used for periodic reviews as needed. The purpose of this module is: To discuss the importance of blood glucose control in the hospital. To orient you to the policies, procedures, and protocols used for inpatient blood glucose control. At the end of this module, you will take a 16 question post-test.

DIABETES RELATED PREVALENCE DATA WHY IS BLOOD GLUCOSE CONTROL SO IMPORTANT IN THE HOSPITAL SETTING? Diabetes prevalence data and research data provide that answer. Ø Diabetes has reached epidemic proportions in the U. S. affecting more than 20 million people. Ø More than 300, 000 Kentuckians have diabetes. Ø One in two Kentucky adults are at risk for developing diabetes. Ø Diabetes is the 5 th leading cause of death in Kentucky. Ø Nationally, about 5, 000 adults are diagnosed every workday. Ø Diabetes is the leading cause of blindness, non-traumatic amputations, and end-stage renal disease. Ø With diabetes, the risk of heart disease and stroke is 2 to 4 times higher than those without diabetes.

DIABETES RELATED RESEARCH SHOWS THAT BLOOD GLUCOSE CONTROL IN THE HOSPITAL WILL HELP DECREASE MORBIDITY AND MORTALITY RATES For Example: Hyperglycemia and: Myocardial Infarction Stroke Cardiac Bypass General Surgery Can lead to: Increased mortality risk Greater disability risk for those admitted with a blood glucose of >120 mg/dl; and, Doubles the mortality risk Increased mortality rate and increased sternal wound infections Increased risk of serious infections (six times the risk of serious infections)

DIABETES RELATED RESEARCH “Diabetes increases the risk for disorders that predispose individuals to hospitalization, including coronary artery, cerebrovascular and peripheral vascular disease, nephropathy [kidney disease], infection, and lower-extremity amputations. Recent studies have focused attention to the possibility that. . . aggressive treatment of diabetes and hyperglycemia results in reduced mortality and morbidity. ” Clement, S. , Braithwaite, M. , et al. Management of Diabetes and Hyperglycemia in Hospitals. Diabetes Care, volume 27, number 2, February 2004, p. 553.

DIABETES RELATED RESEARCH Two landmark research studies (DCCT and UKPDS) showed that keeping blood glucose levels close to normal slowed the onset and progression of eye, kidney, and nerve diseases. ¨ The Diabetes Control and Complications Trial (DCCT) was a clinical study that involved over 1400 people with Type 1 diabetes. ¨ DCCT Study findings included: – – 76% risk reduction in eye disease 50% risk reduction in kidney disease 60% risk reduction in nerve disease 35% risk reduction in cardiovascular disease ¨ The United Kingdom Prospective Diabetes Study (UKPDS) involved over 5, 000 people with Type 2 diabetes. It also showed similar risk reductions.

DIABETES RELATED RESEARCH If the DCCT and UKPDS data are so compelling, why hasn’t it been applied to the hospital setting before? Recommendations needed to be published. In 2003 and again in 2006, the American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists (ACE), based on clinical trial results, made recommendations for the management of hyperglycemia in the hospitalized patient.

DIABETES RELATED RESEARCH Often times diabetes has been undiagnosed during hospitalization and thus untreated. Now we have data proving the importance of inpatient blood glucose control and thus diagnosing diabetes earlier. Based on this data and more, Saint Joseph Healthcare has made the commitment to inpatient blood glucose control for ALL patients regardless of diabetes diagnosis or not.

BLOOD GLUCOSE CONTROL POLICIES, PROCEDURES, and PROTOCOLS Current policies, procedures, protocols, and documentation forms reflect the need for inpatient blood glucose control. They include: Protocols and Standing Orders: Ø Blood Glucose Control Protocol Ø Hypoglycemia Protocol(s) Ø Perioperative Blood Glucose Control Protocol Ø Insulin Pump Standing Orders Ø DKA Standing Orders Ø Non Critical Care IV Insulin Infusion Standing Orders Ø SQ Insulin Standing Orders Documentation Forms: Ø Blood Glucose Section of the Patient Care Flowsheet Ø MAR Ø Blood Glucose Hourly flowsheet Ø Patient Discharge Instructions sheet Ø Admission History (peach color sheet) Ø Treatment Plan: Diabetes section Ø Interdisciplinary Consult and Education Record Policies and Procedures include: Ø Insulin Preparation and Administration Procedure Ø Use of Patient Owned Equipment Ø Insulin (Pharmacy policy) Ø Use of Blood Glucose Control /Diabetes related protocols

BLOOD GLUCOSE CONTROL POLICIES, PROCEDURES, and PROTOCOLS For the purpose of this orientation module for Unit Secretaries, only those forms and procedures that are appropriate to your role will be discussed. The protocols and standing orders are located in the Endocrinology section of the Orders and Forms section of the SJH Intranet. All Protocols and Standing Orders are to be placed in the Orders section of the patient’s chart. Key Points As you now know, blood glucose control is the KEY to decreasing morbidity and mortality rates. (Key Points are special little reminders of importance!)

BLOOD GLUCOSE CONTROL POLICIES, PROCEDURES, and PROTOCOLS So, let’s begin with looking just at the protocols and standing orders! We will begin with the Blood Glucose Control Protocol which was developed in January 2007 and revised in December 2008. It reflects the need to focus on blood glucose control for ALL patients, even those who may not have a diabetes diagnosis but have inpatient blood glucose control issues.

BLOOD GLUCOSE CONTROL PROTOCOL Key Point: This protocol is to be used for all patients who have been admitted for diabetes and any patient with a blood glucose of 150 mg/dl or greater, regardless of diabetes diagnosis or not. Also, please note that it is NOT to be used on OB patients or 23 hour admits or those patients who are admitted with DKA or HHS (hyperglycemic crises) (This is noted in the top left corner of the protocol)

BLOOD GLUCOSE CONTROL PROTOCOL ALL THE ORDERS on this form are AUTOMATIC orders ü That means you will need to take all of them off ! ü It is especially important to make sure the A 1 C and the CMP are ordered!!! ü Note that there are some lines provided to write down the order number ü Some orders do not require an order number, make sure all orders are transferred to the appropriate form Consistent Carbohydrate diet is the type of diet for people with diabetes; ADA is not the correct term. 1800 calories is the default unless ordered differently on the order sheet. ü However, currently the STAR system still lists the diets as ADA or diabetes diet ü Consistent Carbohydrate diet means that the amount of carbohydrates the patient eats will be balanced throughout all the meals and snack for a 24 hour period. FSBG is finger stick blood glucose; frequency is to be AC & HS unless NPO, (0300 x 2 days) etc. or if physician writes a separate order (see order #8). All the other orders listed refer to placing other protocols or standing orders on the chart if appropriate.

BLOOD GLUCOSE CONTROL PROTOCOL KEY POINT: Do NOT automatically consult DNC or DTY unless the doctor writes a separate MD order, OR the nurse tells you to put in a Nursing Referral. Also remember, that an order written for Diabetes Diet instruction does NOT go to the Diabetes & Nutrition Center (DNC), but INSTEAD it goes to Dietary Miscellaneous (DTM) as diet instructions for the dietitian to teach the patient.

BLOOD GLUCOSE CONTROL PROTOCOL OK! That is the Blood Glucose Control Protocol. Even though the Blood Glucose Control protocol is to be initiated on ALL patients with diabetes or those patients with FSBG >150 mg/dl, this protocol still requires a doctor’s signature. So, remember to place a RED “sign here” flag on it. Key Point: Implementing this protocol should become fairly automatic and routine for you!

HYPOGLYCEMIA PROTOCOL There actually 3 different hypoglycemia protocols: – Hypoglycemia Non-pregnant Adult over 100 lbs. – Hypoglycemia Pregnant Protocol – Hypoglycemia Children under 12 years and Adults less than 100 lbs. Again, these protocols are located in the SJHS Intranet in the Orders section under Endocrinology.

HYPOGLYCEMIA PROTOCOL Key Point: The Hypoglycemia protocol does not need a physician’s order to implement it. However, eventually a signature will be needed. So remember to place a RED “sign here” flag on it. The nurse may ask you to print this when needed. It is located in the Orders & Forms section of the SJHS Intranet.

HYPOGLYCEMIA PROTOCOL There is also a “Hypoglycemia Protocol MAR”. This is an MAR that prints automatically with the “Blood Glucose Control Protocol”. This MAR is to be placed behind the current MAR so the nurse has it to use if and when a patient experiences hypoglycemia.

HYPOGLYCEMIA PROTOCOL One last thing regarding Hypoglycemia. . . What would you do if the patient calls out on the intercom and says he is sweaty, feeling light headed, dizzy, shaky, and / or weak feeling? These may be signs of hypoglycemia. You would need to contact the nurse right away and let her / him know of these symptoms. The nurse must treat hypoglycemia immediately!

HYPERGLYCEMIC CRISES STANDING ORDERS The DKA (Hyperglycemic Crises) standing orders are to be implemented on all patients who are admitted with DKA (Diabetic Ketoacidosis) or HHS (Hyperglycemic Hyperosmolar Syndrome).

HYPERGLYCEMIC CRISES STANDING ORDERS When a patient is admitted with DKA or HHS, the physician should be reminded of the availability of this order set and the form placed in the chart. A RED ‘sign here’ flag should be placed on it indicating the need for the doctor’s signature.

IV INSULIN INFUSION STANDING ORDERS There are 2 other insulin drip standing orders: Ø The Non Critical Care IV Insulin Infusion standing orders is for use on the Medical/Surgical and Telemetry units. Ø The Critical Care IV Insulin Infusion standing orders is for use in the Critical Care Units ONLY. Both require a physician’s signature in order to implement them. So, once again, a RED ‘sign here’ flag will be needed. The Non Critical Care IV Insulin Infusion standing orders may require some individualization by the doctor.

BLOOD GLUCOSE HOURLY FLOWSHEET ¨ The Blood Glucose Hourly Flowsheet is to be used ONLY with the Non-Critical Care IV Insulin Infusion standing orders. ¨ One copy will print automatically when the IV insulin infusion standing orders is printed. ¨ Remember to print at least 3 more copies and give them to the nurse for his/her use.

INSULIN PUMP STANDING ORDERS The next protocol is the Insulin Pump standing order set which is to be used on all admitted patients who have an insulin pump.

EXTERNAL INSULIN PUMP INPATIENT ORDERS When a patient is admitted: üPlace this form on the chart üThen place a red ‘sign here’ flag on the form (indicating physician signature is needed) üLastly, but most importantly, place a Diabetes & Nutrition Center (DNC) referral (this is to be done automatically on ALL patients who have an insulin pump) (write insulin pump in the comments section)

PERIOPERATIVE BLOOD GLUCOSE CONTROL PROTOCOL The next protocol is the Perioperative Blood Glucose Control Protocol. This protocol primarily has orders related to FSBG monitoring and what to do with the pre-operative and post-operative diabetes medication orders. Insulin orders may need to be specified by the physician.

PERIOPERATIVE BLOOD GLUCOSE CONTROL PROTOCOL A red ‘sign here’ flag is to be placed on the form indicating physician signature is needed. Key Point: This protocol is to be used only on those admitted surgical patients with diabetes who will come through the Outpatient Surgery Department and PACU.

STAR ORDERING One last reminder about orders. . . . When placing an order for the Diabetes & Nutrition Center, there are 2 line items in the DNC ordering screen. These are: MD Consult for teaching ü This means that the doctor has actually written the order for DNC to come see the patient. Nursing Referral for assessment ü This means that the Nurse wants DNC to come and assess and/or teach the patient. Please make sure you select the appropriate order. This helps DNC to prioritize their work load!

BLOOD GLUCOSE CONTROL POLICIES, PROCEDURES, and PROTOCOLS That ends the section on Protocols and Standing orders. The next section will cover the documentation forms that are used for documenting diabetes care and blood glucose control issues. The first sheet to look at is the Patient Care Flowsheet. As the Unit Secretary, you will be responsible for making sure the Patient Care Flowsheet is available. This is the 24 -hour ‘nursing notes’ for the nurses to document on.

ADMISSION HISTORY (PEACH COLOR SHEET) The next form, the Admission History sheet (peach color sheet) has an Endocrine section located at the bottom of the first page. In this Endocrine section, the nurse might assess the need for a referral to the Diabetes & Nutrition Center (DNC) or Dietary (DTM). So, the nurse may ask you to place a Nursing Referral to either department. Keep in mind that those are actually 2 separate orders to 2 different hospital departments (DNC and DTY).

PATIENT DISCHARGE SUMMARY SHEET The next form, the Patient Discharge Summary sheet, has several places on which to document information related to diabetes. This form is used by the nurse at discharge. It is a duplicate form in which one copy will be given to the patient at discharge and one copy stays on the chart.

TREATMENT PLAN The Treatment Plan (kardex) is printed on a hard paper stock and is used by the nurses to help give report! When you take off orders, you may have to add some orders to this form. There is a Diabetes section to document type of diabetes and FSBG frequency. The back of the Treatment Plan has a lined section that can be used for reminders for diabetes care / blood glucose control issues such as teaching needs, teaching done, insulin pump rates and set changes, etc.

INTERDISCIPLINARY CONSULT AND EDUCATION RECORD The Interdisciplinary Consult and Education record (Care Plan and Caremap) is used to document all initial and ongoing teaching done by the nurse and even other departments. This form is actually the front page of the Care. Map. The nurse may carry this with her/him on their clipboard.

CAREMAP Each Care. Map has a section for daily assessment of Hyperglycemia and Hypoglycemia and whether target blood glucose goals are met or not met. The inpatient target blood glucose ranges, listed on each Care. Map, are: Med/Surg/Telemetry is 70 – 180 mg/dl Critical Care is 80 -110 mg/dl

MEDICATION ADMINISTRATION RECORD (MAR) The last form, the MAR, is one you may be familiar with by now. All oral diabetes medications, basal insulin, bolus insulin, correction insulin, insulin pump rates, and IV insulin drips must be documented on the MAR. All medication doses, time given, and who gave it are documented on the MAR.

MEDICATION ADMINISTRATION RECORD (MAR) As the Unit Secretary, you will be responsible for adding all new medication orders to the MAR. It is important to remember to document the date of the order, the drug name, dose, and frequency. One more reminder, Correction Insulin (the weight based scale) may be pre-printed on stickers, making it easier for you to choose the right weight based scale and then place it on the MAR.

POLICIES & PROCEDURES There are several different policies and procedures related to diabetes and blood glucose control. These include: Ø Ø Insulin Preparation and Administration Procedure Use of Patient-owned Mechanical Equipment while Hospitalized Use of Blood Glucose Control /Diabetes related protocols Insulin (Pharmacy policy) Since the Insulin Preparation and Administration Procedure is for nurses only, we won’t be discussing it. So, let’s briefly look at the others.

POLICIES & PROCEDURES Use of patient owned mechanical equipment while hospitalized policy states ü Since the hospital cannot assure that equipment brought from home is in good working order and that staff may not be familiar with it, home equipment is generally NOT permitted in the hospital. ü Any mechanical equipment brought in by the patient and/or family should be sent home with the family. ü Non-electric equipment (ie, wheelchairs, canes, walkers) can be used in the hospital. All such equipment must be clearly marked with the patient’s name. Patient and family members retain all responsibility for any such item. ü Insulin pumps, however, are an exception and can be used in accordance to the ‘External Insulin Pump’ standing orders.

POLICIES & PROCEDURES The “Use of Blood Glucose Control / Diabetes related protocols” policy discusses the use of all the protocols and standing orders. This Nursing policy is a good reference for when you have questions regarding any of the diabetes or blood glucose related protocols or standing orders.

PHARMACY SERVICES POLICIES The last policy to discuss “Insulin, Human” (064 -IDD-38 C) is actually a pharmacy policy that lists the insulin substitutes. SJHC’s formulary mainly has Novolin insulin products (Regular, Lente, NPH, 70/30) Why do you need to know this policy? Because a physician may write an order to substitute the Novolin brand insulin for a different one. And that’s OK. However, a “Do Not Substitute” order can be written by the doctor and it is to be followed as it is written. After you FAX the order, Pharmacy will then make sure that Substitution is correctly made.

RESOURCES In the Saint Joseph Health System home page, there’s a Department tab. If you click on this you can go into many different hospital departments. If you select the Diabetes & Nutrition Center tab, you will see that it has Nursing Diabetes Newsletters, Diabetes Orders, forms and guides, as well as Diabetes Resources (articles and websites). So, you have some Diabetes resources at your finger tips!

THE FINISH LINE!!! CONGRATULATIONS! You have finished the Blood Glucose Control: Policies, Procedures, and Protocols Learning Module If you have any questions, please contact your Clinical Educator, your unit’s Diabetes Champion, or one of the Diabetes Educators.