1. Health Professions Act Revised Hypoglycemia Protocol Insulin Subcutaneous Sliding Scale Anar Dossa BScPharm CDE September 14, 2007

2. HPA-Health Professions Act What is it? Regulatory framework for health professionals Basic requirements for regulating every health profession are similar Accountability for standards of practice Quality assurance measurements Rigorous registration process Mechanism to review public concerns

3. HPA-Health Professions Act Nursing Implications Increase in scope of practice for registered nurses effective July 1, 2006 Allows registered nurses to initiate certain patient care activities without a doctor’s order

4. WITHIN SCOPE OUT OF SCOPE CRNBC CERTIFIED PRACTICE Nursing practice activities Vital signs Reserved actions without an order Hypoglycemia: initiate IV access & medications Reserved actions with an order Reserved actions for CRNBC certified practice Reserved actions outside scope of practice Not reserved actions Current Practice Section 8 July 1, 2006 Section 9 July 1, 2006 Section 10 August 2007 NP & Delegated Fn CRNBC Standards, Limits & Conditions crnbc 2006 HPA-RN Scope of Practice

5. Controls on Practice CRNBC 2006

6. Provincial Pilots VCH: Hypoglycemia, Wound Care, IV, Tylenol, Oxygen,Catheter IHA: Venipuncture initiation NHA: Catheter initiation VIHA: Oxygen initiation FHWound Care

7. Hypoglycemia Protocol Hypoglycemia is defined as blood sugar less than…

8. Hypoglycemia Protocol Risk factors for hypoglycemia Nutritional status Missed meals, delayed meals Heart failure, renal or liver disease Malignancy Sudden reduction of steroid dose Altered ability of patient to report symptoms Vomiting

9. Hypoglycemia Protocol Risk factors for hypoglycemia New NPO status Reduction in IV dextrose Unexpected interruption of feeds/TPN Altered consciousness from anesthesia Advanced age Previous history of severe hypoglycemia

10. Symptoms Variable from patient to patient Assess patient for his/her individual symptoms

11. Symptoms Trembling Palpitations Sweating Anxiety Nausea Hunger Tingling Clinical Practice Guidelines Can J Diabetes Dec 03 www.diabetes.ca

12. Symptoms Confusion Difficulty concentrating Weakness Drowsiness Vision changes Difficulty speaking Headache Dizziness Tiredness Clinical Practice Guidelines Can J Diabetes Dec 03 www.diabetes.ca

13. Symptoms Night Crying out Night sweats Morning headache Nightmares

14. Symptoms-severe Unresponsive Unconscious Coma Seizure

15. Hypoglycemia Unawareness No warning signals First sign may be loss of consciousness Confusion

16. Hypoglycemia in the Elderly Reduced release of epinephrine and glucagon Cognitive impairment May not be able to communicate in timely manner

17. Beta-blockers and Hypoglycemia What is the concern? Not an absolute contraindication

18. Hypoglycemia Protocol Section A Conscious and able to swallow Section B Conscious but NPO or unable to swallow Tube fed/TPN Section C Unresponsive, unconscious, seizuring

30. Where will these items be kept? D10W Stores item, units to order via stores D50W Omnicell machine Glucagon Omnicell machine Dextrosol Stores item

31. NIA Section 8: Hypoglycemia

32. Follow Up Why did hypoglycemia occur? Should the dose of insulin or oral agent be adjusted?

33. Insulin Subcutaneous Sliding Scale Refer to pre-printed order

34. When should an insulin sliding scale be used? Supplement regularly scheduled insulin or oral diabetes medications May be used as a dose finding strategy Goal is to use as little sliding scale insulin as possible

35. When should this sliding scale not be used? Diabetic ketoacidosis Intravenous insulin

36. Scheduled insulin plus Supplemental insulin Correction-dose insulin Dose-finding strategy Accommodate rapid changes in insulin requirements If correction doses are frequently required, change scheduled dose Insulin Sliding Scale

41. Which sliding scale? Low Intermediate High Custom

42. Low Low or unknown insulin resistance High or unknown insulin sensitivity How do you determine this?

43. Insulin Resistance Determination Insulin Dose (Total Daily Dose) Resistance Level < 0.5 units/kgLow 0.5 – 1 unit/kgIntermediate > 1 unit/kgHigh

44. Low Resistance Thin NPO Renal Failure Elderly

45. High Resistance Obese

46. Insulin Sliding Scale Always use regular insulin Do not give at hs Why? Exception See protocol

47. Follow Up Evaluate total dose q24-48hrs Does the basic dose need to be adjusted?

48. New Insulins on Formulary Insulin Aspart NovoRapid ® Rapid acting insulin analogue Bolus insulin Insulin Glargine Lantus ® Long acting insulin analogue Basal insulin

49. Insulin Aspart Must be given immediately prior to meals Within 15 minutes Risk of hypoglycemia if meal is delayed Can be mixed with NPH as long as the manufacturer is the same Inject immediately after mixing Cannot be given IV

50. Insulin Glargine Cannot be given IV Clear solution Do not confuse with regular or aspart Cannot be mixed with anything

51. Formulary Status Both insulins are restricted Endocrinology For Type 1 patients who experience hypoglycemia or inadequate control on Regular/NPH For patients on these insulins prior to admission

52. Action Profiles of Bolus & Basal Insulins Plasma Insulin levels Hours Note: action curves are approximations for illustrative purposes. Actual patient response will vary. regular 6-10 hours NPH 12–20 hours lispro/aspart 4–6 hours  BASAL INSULINS detemir ~ 6-23 hours (dose dependant) glargine ~ 20-26 hours Mayfield, JA.. et al, Amer. Fam. Phys.; Aug. 2004, 70(3): 491 Plank, J. et.al. Diabetes Care, May 2005; 28(5): 1107-12  BOLUS INSULINS

53. Insulin Comparison InsulinOnset (hrs) Peak (hrs) Dur’n (hrs) Cost per mL Pcare Cov’ge Aspart5-15*1-23-5$2.30Partial Regular0.5-12-46-8$1.24Yes NPH1-26-1218-24$1.24Yes Glargine2-4No peak 20-24$5.51SA** *minutes **special authority

54. Insulin Mixing Regular and NPH OK to mix Resuspend NPH Inject adequate amount of air into NPH Withdraw regular into syringe first Then withdraw NPH What if you don’t do it this way?

55. Questions?