estimated to be complicated by diabetes, and up to 0.5 percent of pregnancies occur in mothers who already have diabetes (Ang, Howe, &

Transcription

1 Title Subtitle author byline Insulin Revisited f in the Maternity Setting For many women who would previously have been instructed to avoid pregnancy, the use of insulin has allowed them to become pregnant and carry those pregnancies to term. Approximately 3 percent to 5 percent of pregnancies are estimated to be complicated by diabetes, and up to 0.5 percent of pregnancies occur in mothers who already have diabetes (Ang, Howe, & Lumsden, 2006). The use of subcutaneous insulin is indicated for mothers when diet and exercise do not maintain their blood sugars within the desirable range ( <95 mg/dl fasting, <140 mg/dl 1-hour postprandial, <120 mg/dl 2-hour postprandial) (American College of Obstetricians and Gynecologists, 2001). Insulin usage to maintain euglycemia has resulted in decreased , AWHONN Helen Hurst, DNP, RNC, APRN-CNM fetal mortality and a reduction in the number of complications in pregnancies complicated by diabetes (Landon, Catalano, & Gabbe, 2007). Consequently, more insulin therapy is now being provided in the antepartum, intrapartum and postpartum settings. Insulin in the Obstetric Setting Standardized practices for the use of insulin are generally in place in all facilities, but do not usually include a specific focus for the obstetric setting. While there are increasing numbers of obstetric patients with diabetes requiring insulin therapy, insulin is still not used with the same regularity in this setting as drugs such as

2 oxytocin, tocolytics and antibiotics. For this reason, nurses, especially those on low-risk units, may have only limited familiarity with insulin usage and may need periodic additional refresher courses in its use. Ensuring patient safety in the arena of insulin therapy requires a multidisciplinary approach that involves the obstetric provider, nurse, pharmacist and dietitian. Insulin Errors Insulin is generally considered safe for the fetus, because it does not cross the placenta. However, major safety issues relate to the consequences of medication errors occurring during insulin therapy. The Institute for Safe Medication Practices (ISMP) lists insulin as a high-alert medication and, along with the U.S. Pharmacopeia, notes that errors in insulin administration continue to be among the most reported medication errors and result in some of the most severe events of all high-alert medications. These errors range from a deficiency in using one of the five rights of medication administration (patient, route, dose, drug, frequency) to the inappropriate use Ensuring patient safety in the arena of insulin therapy requires a multidisciplinary approach that involves the obstetric provider, nurse, pharmacist and dietitian of abbreviations and deficiencies in the knowledge of the nurse providing the therapy (ISMP, 2008). The ISMP also reports that an occasionally noted area of concern is the storage of insulin in open cartons; this practice sets up the possibility of insulin being placed in the incorrect carton, resulting in an insulin error if the drug is identified using the carton rather than the vial. Clinical Practice Recommendations Nursing Competency One of the primary mechanisms to ensure patient safety during insulin use is maintaining the competency of the nurses providing the therapy. All staff should have clearly identified minimum competency expectations that are not merely limited to new employee orientation or previous experience (American Society of Health System Box 1. Guidelines for Insulin Orders Two patient identifiers Specific indication for insulin usage Target range of insulin therapy Insulin type, dosage and route Specific time of administration Blood glucose monitoring regimen Orders for management of hypoglycemia Role of the patient in management of therapy Specific care needs or patient issues Source: American Society of Health System Pharmacists (2006). Pharmacists [ASHSP], 2006). Nurses should have not only the documented knowledge and education to administer insulin, but also easy access to educational materials related to providing insulin therapy. Yearly competency should involve not just a review of how to use the capillary blood glucose (CBG) machine or review of protocols for hypoglycemia. It is suggested that competencies include reviews of the impact of insulin resistance on the pregnant population and overviews of orders routinely used by obstetric providers in the management of patients receiving insulin. Nurses must receive training and review of insulin administration (e.g., measuring, mixing insulins, rotating sites), insulin storage and handling, and key assessments and findings in the obstetric patient requiring insulin. Patient History and Information ASHSP (2006) notes that Joint Commission standards require that the patient s history and health information be readily available to all caregivers. Any history of diabetes should be clearly outlined in the patient s chart, and both pharmacy and nutrition services should be notified. It s important to recognize in obtaining a patient s admit history that many patients do not consider insulin to be a medication. Therefore, it would be helpful to ask, Do you have to give yourself any injections or shots? The patient s history Helen Hurst, DNP, RNC, APRN-CNM, is an assistant professor and BORSF endowed professor in Nursing at the University of Louisiana Lafayette, and a staff labor and delivery nurse at Lafayette General Medical Center in Lafayette, LA. The author reports no conflicts of interest or relevant financial relationships. Address correspondence to: BritRN@aol.com. DOI: /j X x June July 2011 Nursing for Women s Health 245

3 should note all medications, including any over-the-counter products, vitamins or other nutrition supplements and any complementary/alternative medications. Mothers already undergoing insulin therapy in the home setting should be encouraged to bring their insulin to the hospital, but these medications should not be left in the patient s room. Prescribing Practices Inefficient, incomplete or inappropriate prescribing practices, with the most obvious being unclear handwriting of the provider, can lead to subsequent insulin errors. The use of preprinted order sets minimizes the risk of misinterpretation of ambiguous handwriting, and although calling the provider to clarify orders may be necessary, telephone and verbal orders for insulin should be limited and used as the exception rather than the rule. Although nurses are not responsible for prescribing insulin, knowledge of the vital components necessary in orders can minimize errors and may be a valuable tool (see Box 1). Nurses educated in appropriate prescribing practices can prompt providers when items integral to safe practice are missing from insulin orders, resulting in decreased chances of errors due to incomplete orders. Wrong dose Omission of dose Wrong patient Improper monitoring, timing and assessment of blood glucose results five rights of medication administration continue to be an issue during insulin therapy. Efforts to maintain the integrity of the five rights include preparing the insulin dose at the bedside; bringing the medication administration record into the room and using two patient identifiers; using an insulin syringe only; and checking the dose, the type of insulin and the ordered dose with a second nurse at the bedside. Intravenous (IV) insulin therapy involves additional significant possible areas of error, especially in the obstetric arena, where there may be multiple IV and epidural lines in use (Broussard, 2009). All insulin IV infu sions should be on an IV pump that has free flow protection and smart pump capabilities that have defined rates and alerts. Furthermore, insulin IV tubing should be labeled at the distal end closest to the patient (ASHSP, 2006). See Box 3 for practices to reduce the risk of insulin errors. Failure to properly adjust insulin therapy Monitoring Administration While the use of standardized practices and procedures in all the areas of the preparation of insulin therapy is essential, it s ultimately the nurse who holds the responsibility for the correct administration of the drug. A policy should clearly delineate who is to perform the CBG before insulin administration, with the ideal practice being that the RN who is to administer the insulin will be the person who performs the CBG. This procedure removes the risk of miscommunication of blood glucose values that could result in an inappropriate insulin dosage. Administration not only encompasses knowledge of the insulin itself, but concurrent knowledge and management of both hyper- and hypoglycemia. As noted in Box 2, errors in the Box 2. Most Common Insulin Errors Wrong type of insulin Wrong route Wrong time of dose Source: American Society of Health System Pharmacists (2006). 246 Nursing for Women s Health Deficiencies in the monitoring and administration of insulin are the most common causes of hyperglycemia Volume 15 Issue 3

4 and hypoglycemia (Smith, Winterstein, Johns, Rosenberg, & Sauer, 2005). Following the administration of insulin, the nurse plays a vital role in assessing any subsequent episodes of hypoglycemia and managing those events. Blood glucose monitoring is an important tool in the evaluation of the effectiveness of insulin therapy. The perinatal unit should have established standard monitoring times for blood glucose that reflect meal delivery times. Furthermore, Following the administration of insulin, the nurse plays a vital role in assessing any subsequent episodes of hypoglycemia and managing those events policies should dictate the timing of insulin administration after a blood glucose measurement. For example, the insulin must be given within 15 minutes following blood glucose measurement; if insulin is not given within 15 minutes, the blood glucose should be repeated. Standard order sets should be available for the management of hypoglycemic events, with specific guidelines for the notification of the provider. Nutrition The pregnant patient with diabetes who is undergoing insulin therapy has unique needs in the area of therapeutic nutrition. Further comorbidities, such as hyperemesis, pre-eclampsia and preterm labor, can further complicate the clinical picture. A dietetics consult should be ordered before insulin therapy, with periodic evaluation of the patient s condition in order to maximize nutritional intake. The nurse must keep the dietitian apprised of changes in the patient s status and therapy in order to reevaluate and adjust carbohydrate needs. The nurse should also assess the carbohydrate intake of the patient at each meal and this should be noted along with blood glucose results and insulin doses (ASHSP, 2006). Patient and Family Education The patient s participation in insulin therapy provides an additional safety net. Providing the patient with basic information such as type, dose, route and time may help prevent medication errors. A daily printed plan given to the patient before bed or early in the morning can explain the plan for CBG measurement and insulin therapy during the day. The patient then becomes an empowered active participant in safety and care. Family members who are with the patient should be educated on signs and symptoms of hypoglycemia so that they can be an adjunct in monitoring for adverse events. Self-Care Discharge planning and self-care is an integral part of the management of the insulin-dependent patient. The inpatient setting is providing an ideal environment for administration and monitoring that may not reflect what will happen when the patient returns home. Before discharge the mother s ability to accurately perform CBG measurement and mix and administer insulin needs to be evaluated. Ideally, from the very first CBG and dose of insulin, she should be educated by the nurse on the procedure while being slowly introduced into performing it herself. This can begin with a step-by-step building procedure, such as with the CBG, by having her first prepare her finger for the stick, the next Box 3. Practices to Reduce Risk of Insulin Errors Preprinted orders Standardized insulin order sets Elimination of insulin sliding scales without basal insulin therapy Not using abbreviations that could cause confusion or error Independent second-person verifications No storing of insulin in open cartons Adoption of standardized insulin terminology Source: American Society of Health System Pharmacists (2006). June July 2011 Nursing for Women s Health 247

5 motivation! obstetric patient with diabetes, organizations, obstetric providers and nurses play a vital role in reducing the chance of medication errors and subsequent adverse events. Continued recognition of the inherent hazards of insulin usage, and diligent education and evaluation of insulin procedures in this patient population, can improve outcomes for both mothers and infants. NWH References American College of Obstetricians and Gynecologists. (2001). ACOG practice bulletin no. 30: Gestational diabetes. Washington, DC: Author. time perform the stick, the next time placing the strip in the machine, etc., and likewise with the administration of the insulin. Repetition of these procedures is the key to the mother becoming both comfortable and accurate, therefore, waiting until the day she is discharged is ineffective in assuring both safety and competency. A dietetics consult with an accurate evaluation of the patient s dietary habits should be performed, including snacking habits, times that she becomes hungry and food preferences. Too often the mother is told to follow a specific caloric diet with little attention given to directing her on how to achieve this in relation to her normal food intake. This may be particularly challenging for patients with lower educational levels, who may require more frequent followup to ascertain compliance. The use of food diaries can be integral in monitoring and modifying dietary requirements; this not only allows providers to be aware of food intake, but can provide the mother with greater awareness of how much food she is eating and how she feels in relation to differing blood glucose values. Just as people on diets for weight 248 Nursing for Women s Health control find that they are able to be more in control of their intake when tracking food, the diabetic mother may be more likely to be compliant with the prescribed diet if she is writing her intake down in a diary. Communication Communication with the primary provider is an integral part of insulin therapy and management. The nurse must update the provider with changes in the patient s status (e.g., vomiting, changes in appetite and amount of food being consumed) that could impact blood glucose values. Blood test results that may impact the accuracy of blood glucose values, such as low or high hematocrit or dehydration, should be reported to allow ordering of venous blood glucose measurement if indicated (ASHSP, 2006). Furthermore, the provider should communicate with call partners and make them aware of the assessment, therapy and management plan before signing-off care of the patient on weekends, holidays or other times. American Society of Health System Pharmacists. (2006). Professional practice recommendations for safe use of insulin in hospitals. Bethesda, MD: Author. Retrieved from resource.aspx?resourceid=3293 Ang, C., Howe, D., & Lumsden, M. (2006). Diabetes. In D. James, P. Steer, C. Weiner, & B. Gonik (Eds.), High risk pregnancy: management options (4th ed.). Philadelphia: Elsevier Saunders. Broussard, B. S. (2009). Tubing safety in the obstetric setting: Preventing medication errors. Nursing for Women s Health, 13(2): Institute for Safe Medication Practices. (2008). ISMP Medication Alert. Retrieved from newsletters.acutecare/ articles/ asp Landon, M. B., Catalano, P. M., & Gabbe, S. G. (2007). Diabetes mellitus complicating pregnancy. In S. G. Gabbe, J. R. Niebyl, & J. L. Simpson (Eds.), Obstetrics: Normal and problem pregnancies (5th ed., pp ). Philadelphia: Churchill Livingston. Smith, W. D., Winterstein, A. G., Johns, T. E., Rosenberg, E. I., & Sauer, B. C. (2005) Causes of hyper- and hypoglycemia in adult medical and surgical patients. American Journal of Health System Pharmacists, 62, Conclusion As insulin therapy continues to be a valuable adjunct in the care of the Volume 15 Issue 3