Glycemic Management Hypoglycemic & Hyperglycemic Treatment Continuing Care

Transcription

1 Approved by: Glycemic Management Hypoglycemic & Hyperglycemic Continuing Care Senior Operating Officer, Addiction & Mental Health and Continuing Care, Edmonton Senior Operating Officer, Rural Services Corporate Policy & Procedures Manual Number: VII-C-120 Date Approved May 9, 2018 Date Effective Next Review (3 years from Effective Date) June 2021 Purpose To outline expectations and recommended strategies for glycemic management of residents in continuing care settings. Policy Statement Covenant Health health-care professionals shall follow the guidelines identified in this policy, and corresponding procedures when caring for residents who require glycemic management and possible treatment of hyperglycemia or hypoglycemia. Applicability This policy and procedure applies to Covenant Health continuing care facilities, staff, medical staff, volunteers, students and any other persons acting on behalf of Covenant Health. Principles The approach to therapy for diabetes in older people should be different from that in younger people, especially in the frail elderly or those with dementia or limited life expectancy. Personalized strategies are needed to avoid overtreatment. Glycemic management is unique to each older individual and is to be consistent with how residents desire to have their diabetes managed and in consideration of their Advanced Care Plan/ Goals of Care Designation (ACP/GCD). The potential benefits of treatment are to be balanced against the potential risks of harm (e.g. hypoglycemia, hypotension, falls). Glycemic management is required to support residents to meet their blood glucose targets, which is an A1C of less than 8.5%, to mitigate the risks associated with hypoglycemia and hyperglycemia including exacerbation of acute illness, promoting wound healing, preventing infections and avoiding other complications. Elements 1. Targets 1.1 Glycemic targets should be individualized based on age, duration of diabetes, risk of severe hypoglycemia, presence or absence of cardiovascular disease, and life expectancy 1.2 Recommended blood glucose target levels for elderly residents in the continuing care population are usually between 5-12 mmol/l. EXCEPTIONS may include residents with a guarded diagnosis (i.e., end of life); those who have been identified to have hypoglycemia unawareness; the frail elderly; and residents with multiple co-morbidities.

2 VII-C-120 Page 2 of For residents whose blood sugars are to be outside of the recommended range, the most responsible health practitioner should identify the target range on the resident's chart. 1.4 Consider a medication review and titration of insulin doses if not achieving target blood glucose values. 2. Procedure for Glycemic Management 2.1 Monitoring blood glucose: Resident-specific testing regime should be determined in consultation with the health care team, based on type of diabetes, treatment, and the need for information Capillary blood is not recommended for blood glucose testing for residents with severely impaired peripheral circulation (e.g., hypovolemia, shock) Blood Glucose Monitoring Frequency per Canadian Diabetes Association Guidelines available in 'Resources' on A-Z page on compassionnet For patients with type 2 diabetes who are managed with lifestyle, with or without oral anti-hyperglycemic agents associated with low risk of hypoglycemia, and who are meeting glycemic targets, very infrequent checking may be needed. 2.2 Insulin Therapy Appropriate subcutaneous (SC) insulin prescription: Insulin is the most appropriate agent for effectively controlling hyperglycemia, including when oral agents are not safe or effective for residents with type 2 diabetes Timing of insulin administration should be coordinated with meals and blood glucose testing Capillary blood glucose testing should be done 30 minutes prior to meals, and Insulin should be administered based on this test no more than 30 minutes prior to meals in most instances. short acting insulin should be given 30 minutes prior to a meal, and rapid acting insulin should be given just before a meal.

3 VII-C-120 Page 3 of 12 Exception: Meal insulin may be given immediately after the meal/feed in certain situations (e.g., gastroparesis or concern that the resident may not be able to ingest or retain the full meal). 2.3 Consideration of the effects of oral anti-hyperglycemic medication may also be necessary when timing meals and blood glucose testing. 2.4 Residents with diabetes benefit from individualized nutritional support, with a consistent carbohydrate meal planning system. 2.5 For residents with insulin pump therapy (IPT): 3. Documentation If the insulin pump is stopped, basal insulin must be replaced within two hours to prevent diabetic ketoacidosis (DKA). Severe hyperglycemia and/or DKA can result when IPT is stopped for as little as 2-4 hours and the insulin is not replaced; even if blood glucose values are normal or low when the pump is discontinued. Document the following information in the resident s health record: 3.1 Resident s symptoms, treatment provided and response to treatment. 3.2 Notification of other health care team members. 3.3 Resident/family teaching.

4 VII-C-120 Page 4 of 12 PROCEDURE FOR TREATMENT Hypoglycemia Refer also to Appendix A - Quick Reference: of Hypoglycemia 1. Appropriate assessment and treatment of asymptomatic and symptomatic hypoglycemia includes, but is not limited to: 1.1 Early recognition: A hypoglycemic state may be asymptomatic or symptomatic. Symptoms of hypoglycemia may include, but are not limited to: a) Early / Non-severe symptoms: (iii) (iv) (v) (vi) (vii) (viii) (ix) (x) (xi) headache; mood changes; irritability; tremors; tiredness; tachycardia; excessive hunger; diaphoresis; pallor; paresthesia; and/or inability to concentrate. b) Advanced/severe symptoms may include all of the above as well as: (iii) (iv) being unable to recognize and treat hypoglycemia by self; disorientation; altered level of consciousness, including unconscious state; seizure. 2. of Hypoglycemia 2.1 Applicable for all residents with a blood glucose less than 4 mmol/l, even those asymptomatic: An order is not required to implement this procedure, provided that a health care professional has determined that the resident meets the specific circumstances and implementation criteria outlined Avoid overtreatment of hypoglycemia to prevent rebound hyperglycemia; Note: 15 grams of fast-acting carbohydrates is usually sufficient for managing hypoglycemia for residents who are able to have oral intake.

5 VII-C-120 Page 5 of Decreasing insulin doses based on prescriber s order rather than holding or discontinuing to promote glycemic management; and Contact the most responsible health practitioner when indicated 2.2 of Hypoglycemia in Resident Who is Conscious: (for quick reference table see Appendix A) Able to Swallow and NOT NPO Resident who has a Tube Feed Resident with Dysphagia Where the health care professional identifies a state of hypoglycemia, treatment shall be initiated, as per this procedure The most responsible health practitioner shall be contacted and informed if the resident s condition changes to an advanced/severe state of hypoglycemia; and when otherwise specified in this procedure Provide 15 grams (or as close as possible) of a quick acting carbohydrate. Choose one of the following: a) 4 dextrose tablets (16 grams [g] of carbohydrate); or b) 3/4 cup or 175 ml juice or regular pop; or c) 2 individual packages (or 15 ml) of honey; or d) 4 packets of sugar dissolved in water. Exceptions: (iii) If the patient is taking acarbose for glycemic control, use dextrose tablets or honey only, as acarbose delays the absorption of sucrose. If the patient has a tube feed, provide juice and flush with water (pre and post juice). For patients with dysphagia, give honey Repeat capillary blood glucose test in 15 minutes. a) If the patient s blood glucose result is below 4 mmol/l, repeat treatment with 15 grams of quick acting carbohydrate. Retest in 15 minutes. If blood glucose remains below 4 mmol/l, contact the most responsible health practitioner for further treatment.

6 VII-C-120 Page 6 of 12 Note: If the patient becomes unresponsive or has altered level of consciousness, proceed to Section 3. b) If the patient s blood glucose result is greater than or equal to 4 mmol/l AND the next meal is more than one hour away, provide a snack consisting of approximately 15 grams of carbohydrate and a protein source. Choose ONE of the following suggested snack options: (iii) (iv) ½ of a meat or cheese sandwich (1 slice of bread and 1 ounce or 30 grams of meat or cheese); or 3 packages of soda crackers (two crackers per package) with either: 1 package of peanut butter (1 tablespoon or 15 g per package), or 1 package of cheese (1 ounce or 30 g per package); or 2 packages of arrowroot cookies (2 cookies per package) with either: 1 package of peanut butter (1 tablespoon or 15 g per package), or 1 package of cheese (1 ounce or 30 g per package); or 1 slice of toast/bread with either: 1 package of peanut butter (1 tablespoon or 15 g per package), or 1 package of cheese (1 ounce or 30 g per package). Exceptions: For patients with dysphagia on minced/puree diets provide: 1 container of Ensure or Boost pudding (115 g); or 1 container smooth Greek yogurt (100 g). Note: If neither available; discuss appropriate snack options with dietitian. For patients on tube feed: if tube feed is continuous, continue regular feeding at established rate; or if tube feed is intermittent, give 100 ml bolus of ordered formula and resume feeding at next scheduled time. c) If meal is less than one hour away, give the meal only and do not provide a snack.

7 VII-C-120 Page 7 of of Residents with Altered Consciousness/Unable to Swallow (includes those who are NPO) Where the health care professional identifies an advanced/severe state of hypoglycemia, the most responsible health practitioner shall be contacted and informed of the patient s change in status If patient has an altered level of consciousness, place in the recovery position to maintain an open airway Administer glucagon 1 mg subcutaneously or intramuscularly (SC or IM) Note: administer glucagon while the most responsible health practitioner is being contacted regarding the patient s condition. Do not delay treatment and consider calling Repeat capillary blood glucose test in 15 minutes. a) If blood glucose is greater than or equal to 4 mmol/l and patient is conscious, and able to swallow (not NPO) proceed to Section b & c for snack options b) If blood glucose is below 4 mmol/l and patient is conscious/able to swallow: provide 15 grams (or as close as possible) of a quick acting carbohydrate. [See section 2.2.3] repeat capillary blood glucose test in 15 minutes. c) If blood glucose is below 4 mmol/l, and patient continues to have altered level of consciousness, is unable to swallow or is NPO, administer glucagon 1 mg SC or IM followed by: repeat capillary blood glucose test in 15 minutes; and contact the most responsible health practitioner for further treatment if blood glucose remains below 4 mmol/l Ongoing Monitoring and Resident Education Repeat capillary blood glucose test one hour after the hypoglycemic event.

8 VII-C-120 Page 8 of Resume insulin schedule or oral anti-hyperglycemic medications unless otherwise ordered. Contact the most responsible health practitioner if unsure Review resident understanding of the hypo glycemic event and provide education as appropriate PROCEDURE FOR TREATMENT Hyperglycemia 1. Appropriate assessment and treatment of hyperglycemia includes, but may not be limited to: 1.1 Vital signs; 1.2 Medication review (i.e. regular insulin dosing schedule, timing of last insulin administration, held or missed insulin, etc.); 1.3 Last carbohydrate administration/ingestion 1.4 Contacting the most responsible health practitioner for further orders, when the resident s blood glucose is greater than 20 mmol/l and/or when otherwise indicated in resident specific orders. 1.5 An order is not required to implement this procedure, provided that a health care professional has determined that the resident meets the specific circumstances and implementation criteria outlined. 1.6 Symptoms of significant hyperglycemia include thirst, tiredness, polyuria, dizziness, nausea, vomiting, blurred vision, lethargy, sweet smelling breath, and hyperventilation. Hyperglycemia may be due to: a) insufficient insulin; b) insulin omission; and/or c) recent ingestion of carbohydrate. 2. of Hyperglycemia 2.1 Provide insulin or oral antihyperglycemic medications and monitor blood glucose as ordered. 2.2 If blood glucose is greater than 20 mmol/l:

9 VII-C-120 Page 9 of Contact the most responsible health practitioner for further orders. (The most responsible health practitioner should consider physical and/or lab assessment to rule out Diabetic Keto-Acidosis in patients with Type 1 diabetes.) Do not promote activity/exercise (i.e., physiotherapy) Encourage intake of water if no restrictions 3. Ongoing Patient Monitoring and Education 3.1 Once the patient's glycemic status has stabilized, recommence routine blood glucose monitoring and/or increased monitoring as ordered. 3.2 Review the recent hyperglycemic event(s) and look at efforts to prevent a recurrence. 3.3 Review resident/family understanding of the hyperglycemic event and provide education/training as appropriate. Definitions Health care professional means an individual who is a member of a regulated health discipline, as defined by the Health Disciplines Act [Alberta] or the Health Professions Act [Alberta], and who practices within scope and role. Most responsible health practitioner means the health practitioner who has responsibility and accountability for the specific treatment/procedure(s) provided to a resident and who is authorized by Covenant Health to perform the duties required to fulfill the delivery of such a treatment/procedure(s), within the scope of his/her practice. Related Documents/ Resources APPENDIX A Quick Reference Chart: of Hypoglycemia Frequency & Pattern Tool (interactive) for Blood Glucose Monitoring: Lows and Highs: blood sugar levels (resources for Residents) Self-Monitoring of Blood Glucose (SMBG) Recommendation Tool for Healthcare Providers References Diabetes Canada. Clinical Practice Guidelines Accessed April 23, Monitoring Glycemic Control cht 9 : Hypoglycemia cht 14: Diabetes in the Elderly cht 37: Quick Reference-Frail Elderly:

10 VII-C-120 Page 10 of 12 Revision Date(s) N/A

11 VII-C-120 Page 11 of 12 APPENDIX A Quick Reference: of Hypoglycemia Section 1 Resident is Conscious -- Able to Swallow and NOT NPO; -- has a Tube Feed; --has Dysphagia Provide 15 grams of a quick acting carbohydrate. a) 4 dextrose tablets (16 grams [g] of carbohydrate); or Choose one of: b) three-quarters (3/4) cup or 175 ml juice or regular pop; or c) 2 individual packages (or 15 ml) of honey; or d) 4 packets of sugar dissolved in water. If the patient is taking acarbose for glycemic control, use dextrose tablets or honey only, as acarbose delays the Exceptions: absorption of sucrose. If the patient has a tube feed, provide juice and flush with water (pre and post juice). For patients with dysphagia, give honey. Repeat capillary blood glucose test in 15 minutes. A. or B. A. If the patient s blood glucose result is less than 4 mmol/l Provide 15 grams of a quick acting carbohydrate as above. If resident remains responsive: repeat capillary blood glucose test in 15 minutes if below 4 mmol/l contact most responsible health practitioner for further treatment if resident becomes unresponsive proceed to section 2 B. If the patient s blood glucose result is greater than or equal to 4 mmol/l AND the next meal is more than one hour away provide a snack consisting of approximately 15 grams of carbohydrate and a protein source -- see of Hypoglycemia, Section b) for snack options If meal is less than one hour away, give the meal only and do not provide a snack. Repeat capillary blood glucose test one (1) hour after the hypoglycemic event Resume insulin schedule or oral antihyperglycemic medications unless otherwise ordered. Document patient s symptoms, treatment provided and response to treatment.

12 VII-C-120 Page 12 of 12 APPENDIX A continued Section 2 Resident Has Altered Consciousness - Unable to Swallow (includes those who are NPO) Place in the recovery position to maintain an open airway glucagon 1 mg subcutaneously or intramuscularly (SC or IM) Administer Note: administer glucagon while the most responsible health practitioner is being contacted regarding the patient s condition. Do not delay treatment and consider calling 911 Repeat capillary blood glucose test in 15 minutes. A., B., or C. A. If blood glucose is greater than or equal to 4 mmol/l and patient is able to swallow (not NPO) Follow of Hypoglycemia, Section b & c for snack/meal options B. If blood glucose is below 4 mmol/l, and patient continues to have altered level of consciousness, is unable to swallow or is NPO C. If blood glucose is below 4 mmol/l and patient regains consciousness and is able to swallow: administer glucagon 1 mg SC or IM followed by: repeat capillary blood glucose test in 15 minutes; and contact the most responsible health practitioner for further treatment if blood glucose remains below 4 mmol/l. provide 15 grams (or as close as possible) of a quick acting carbohydrate. [See section 1. above] Repeat capillary blood glucose test in 15 minutes and (iii)contact the most responsible health practitioner for further treatment if blood glucose remains below 4 mmol/l. Document patient s symptoms, treatment provided and response to treatment.