New Subcutaneous Insulin Protocol for Type 2 Diabetics Becky Anthony RN, BSN,CDE Stacey DiModica RN, BSN, CDE

What the New Insulin Protocol does? Introduces the concepts: basal, prandial, correctional insulin doses More individualized insulin ordering based on patient’s weight, age, renal function, and history of insulin use A Standardized Hypoglycemia Protocol Standardized correctional scales based on level of Insulin sensitivity/resistance

Target Goals for Glucose Levels Critical Care Units: Select Patients (Cardio-Thoracic Service): 110-140 mg/dl All other Critical Care Patients: 140-180 mg/dl Initiate Insulin Therapy > 180 mg/dl on two occasions Non-Critical Care Units: Fasting and Pre-prandial 140 mg/dl Initiate Insulin Therapy > 180 mg/dl Note: This includes all patients (Diabetics and Non-Diabetics) AACE/ADA Inpatient Glycemic Control Panel, Endocrine Practice 2009;15(4). During hospitalization, there are accepted upper limits for glycemic targets, which are listed in this slide. These targets have been based on an analysis of studies performed in the ICU and in non-critical care units. In the ICU, for example, maintaining glucose levels of 110 mg/dL was found to promote recovery in both the short and long-term.

“Stop Sliding”: Challenges with a Sliding Scale Non-physiologic strategy is a “reactive” rather than a “proactive” and a corrective response to blood glucose Fails to incorporate Basal and Nutritional requirements Typically requires hyperglycemia before intervention No Standardization in orders Promotes “roller coaster” blood glucose effect Increases the risk of hypoglycemia Sliding scales are not physiologic in nature, and are a reactive (not proactive) response to blood glucose; they call for the treatment of hyperglycemia after it is already present, rather than preventing it from developing. The reactive approach can lead to rapid fluctuations in blood glucose levels (the “roller coaster” effect).

Proper Matching Lispro and Meals Insulin given 0-15 mins pre-meal Glucose Level Efforts should be made to match the increases in blood glucose levels with the glucose-lowering effect of insulin. As this illustration shows, the use of rapid-acting insulin can be matched with increases in glucose levels associated with consuming a meal. 1 2 3 4 Time in Hours

OPTIMAL PRACTICE Glucose Check Glucose Check Glucose Check 0800 1200 Meal & Insulin Meal & Insulin Meal & Insulin 0745 1145 1645 0800 1200 1700

Physiologic Insulin: Terminology Basal: Insulin required to meet the metabolic needs in between meals Mealtime: (Pre-Prandial) Insulin required for meal coverage Correctional: Insulin required for unexpected hyperglycemia This slide provides a definition of terms – “programmed/scheduled insulin” and “supplemental/correctional doses” – as described in a recent American Diabetes Association review. Clement, Diabetes Care 2004;27(2):553-591

Timing of Insulin Administration 22:00 Give long acting Basal insulin Pre-breakfast: Test blood glucose Pre-prandial dose + Corrective dose Total Pre-breakfast dose Pre-lunch: Test blood glucose Pre-prandial dose Total Pre-lunch dose Pre-dinner: Test blood glucose Pre-prandial dose Total Pre-dinner dose

There are different Correctional Scales and different Bedtime scales determined by the MDs order. Your EMAR screen will pull the doses from the order Just so you understand all scales could be different

What your EMAR screen will look like When you click on insulin, you will first get a question If yes: Prandial or mealtime doses will fill the next screen If no: No prandial doses will fill in and you will only give correctional insulin based on the patient blood glucose

What your EMAR screen will look like If Eating Enter Blood glucose Night sliding scale may be different than mealtime scale Enter time of Day B= breakfast, L= lunch D= dinner and N=night

If not eating a meal, hold prandial Patient will still need basal order and adjustment for high blood glucose When you say the Patient isn’t eating no Prandial dose will appear

If for any reason the patient, the dose to be given is different from the total units: document reason and notify MD

Changing from Enteral feeds to Eating Be cautious when patients change from enteral feeding to eating. Patients on enteral feeding will have a separate order To cover their meals. When they start to eat, that order must be discontinued And this insulin protocol should be started. The most you should have is one basal dose, one prandial and one correctional dose.

Hypoglycemia protocol : for patients who can eat

Hypoglycemia Protocol If BG < 70, Initiate Treatment If able to swallow safely: Give 15 grams of “quick-acting” carbohydrate Wait 15 minutes Re-test glucose level Repeat treatment if glucose remains <70 mg/dl Provide snack if next scheduled meal is > 1 hour The protocol for hypoglycemia is typically implemented in patients whose blood glucose level is less than 60 mg/dL, even if he or she is asymptomatic. For patients able to swallow safely, they should receive 15 grams of “quick-acting” carbohydrate (such as fruit juice); this treatment should be repeated in 15 minutes if blood glucose levels remain low. Keep in mind that overtreatment of these patients is common, with treatments given at much higher glucose levels than is warranted.

Hypoglycemia Protocol: Options for Oral “Quick-Acting” Carbohydrate Fruit juice 4 oz. (apple, grape, cranberry) Regular Ginger-ale or Cola 6 oz 1 tablespoon of sugar (or 4 packets of sugar) 1 tablespoon of honey 1 tablespoon of jam or jelly 3-4 Glucose or Dextrose Tablets Eight ounces of milk (whether whole, low-fat or nonfat) provide 15 grams of carbohydrate. So do 4 ounces of fruit juice. Glucose tablets can be taken as well, and they provide a consistent amount of carbohydrate (whereas the carbohydrate content of juice can vary depending on the ripeness of the fruit when it was packaged). Another advantage of glucose tablets is that they can be safely used for the patient with renal failure, and are preferable to orange juice in this case.

Hypoglycemia Protocol: For Patients who are NPO and have IV access

Hypoglycemia Protocol: For Patients who can’t eat and don’t have an IV

Strategies for Timing of Glucose Monitoring, Insulin, & Nutrition Nursing Strategies Monitor BG within 15 minutes of the meal 7:45am, 11:45am, 4:45pm Diabetic meal trays to be delivered at 8:00am, 12:00pm, and 5:00pm Administer insulin when the meal tray is present Patient Involvement: Have the patient use the call bell when tray arrives to cue the nurse to give the insulin on time Whenever possible, medications and meals should be given to patients at times that maintain optimal glycemic levels. Ideally, blood glucose levels should be measured within 30 minutes of a meal, particularly if a sliding scale is being used.

Strategies for Timing of Glucose Monitoring, Insulin, & Nutrition Nursing Strategies • If a patient leaves the nursing unit for a test, REPEAT the glucose test upon return to the unit and administer insulin when the tray is present • If the patient received the mealtime insulin dose, ensure they have eaten before leaving the unit for a test Nurses can serve as patient advocates, and urge the scheduling of hospital procedures in the early morning in order to interfere as little as possible with the proper timing of meals. When delays or disruptions in eating occur, however, nurses should assess the patient’s glucose levels both before and after the procedure, and respond appropriately to variations in blood glucose.