HYPERGLYCEMIA MANAGEMENT PROTOCOL A BASAL/BOLUS REGIMEN. Kacy Aderhold, MSN, APRN-CNS, CMSRN

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1 HYPERGLYCEMIA MANAGEMENT PROTOCOL A BASAL/BOLUS REGIMEN Kacy Aderhold, MSN, APRN-CNS, CMSRN

2 Hyperglycemia Management Protocol Mimics the body s normal pancreas function, releasing a slow steady amount of basal insulin in between meals and bedtime to cover the sugar from the liver and a burst of insulin to cover food. Doses are dependent on patient s sensitivity to insulin. Hospitalized patients are often insulin resistant and require more insulin when ill than when they are well. Patients may become more insulin sensitive as they recover.

3 INTEGRIS Baptist Medical Center is the only organization in the country certified by The Joint Commission for Hyperglycemia Management!

4 Quality Diabetes Care Several Studies examine results of best-practice with reduction in length of stay. One of these studies was performed at INTEGRIS Baptist Medical Center: The Benefits of Inpatient Diabetes Care: Improving Quality of Care and the Bottom Line The use of an intensified inpatient protocol by a diabetes management team resulted in correct coding and treatment of patients with previously unrecognized hyperglycemia. The LOS was reduced for both primary and secondary diagnoses of diabetes, and readmission rates declined. ADA/AACE 2009 Consensus Statement on Inpatient Glycemic Control p. 1126

5 Hyperglycemia Management Protocol The HMP must be ordered by a physician/aprn/pa. Nurses may suggest this protocol to our colleagues but may not implement without an order. Many powerplans, have an order sentence stating to initiate the HMP if FSBS >140. Comprised of 3 basic steps- basal, correctional & nutritional insulin Once implemented, nurses may adjust doses appropriately. Replaces all previous insulin orders Replaces sliding scale

6 FSBS & Basal Insulin

7 Correctional Insulin Also referred to as x This step replaces former sliding scales 100 represents the target blood sugar The X for the correction factor represents the patient s insulin sensitivity. If a specific corrective factor is not specified by the ordering physician/aprn/pa, the default is X=25.

8 For example: If a patient has an x of 25 and their FSBS was 150, how much insulin would you give them for their correctional dose? 2 units

9 Nutritional Insulin Also referred to as y Different formulas for a patient that is eating, on tube feeding, or on TPN

10 Patients that are eating FSBS QIDAC & HS Aspart Insulin Subcut Carb count will be on meal slip of all meals/snacks Corrective and nutritional doses given separately Wait until end of meal and count carbs consumed, not carbs on tray If x was a negative #, subtract that # from the y dose

11 For example: If a patient has a y of 10 and they ate 100 carbs, how much insulin would you give them for their nutritional dose? 10 units aspart

12 FSBS 100 mg/dl If the patient s BG is 100 mg/dl, you will calculate a negative number for your corrective dose. This negative number is very important. It should be added to (or subtracted from) the nutritional dose in order to prevent HYPOglycemia.

13 For example: If a patient has an x of 5 and a y of 4. Their FSBS was 88 and they ate 60 gm of carbs. How much insulin would you give them? 13 units

14 Patients that are on Continuous Tube Feeding FSBS Q4 Regular Insulin Subcut G carbs/ml can be found on page 2 of the HMP or may be calculated from can. Add this number to corrective insulin dose (If x was a negative #, subtract that # from the y dose) Remember you are giving insulin dose to treat upcoming 4 hours

15 For example: Your patient has an x of 25 and a y of 10. They are on Glucerna at 60mL/hr. Their FSBS was 200. How much insulin would you give them? 6 total units of regular insulin (for upcoming 4 hours of tube feeding)

16 Patients that are on TPN FSBS Q4 Regular Insulin Subcut TPN Dextrose % can be found on the TPN orders or on the bag (usually 20%). Add this number to corrective insulin dose (If x was a negative #, subtract that # from the y dose). Remember you are giving insulin dose to treat upcoming 4 hours.

17 For example: Your patient has an x of 25 and a y of 10. FSBS was 75. They are on TPN at 95mL/hr. There is 20% dextrose in the TPN mixture. How much insulin would you give your patient? 7 units regular insulin, could even give 6 units

18 What about bolus tube feedings? Treat like food. You may have to divide the number of carbs in the can by the number of mls in the can to calculate your dose (or you can use your cheat sheet).

19 When you may not need a Y.. When the following DM medications are ordered: (Unless ordered by Endocrine or Glucose Management Services) Glipizide Glyburide Glimepiride 70/30 insulin These medications stimulate the pancreas to produce more insulin to cover the food the person is eating. The 30 of 70/30 insulin is the nutritional coverage. Since the patient is receiving these medications, he/she does not need Y coverage or it would be double dosing the patient.

20 FSBS greater than 300mg/dL Remember the duration and actions of insulin. Dosing insulin too close together may result in hypoglycemia from insulin stacking.

21 Nurses can adjust the x and y! Level 1 default for patients with Type 1 Diabetes Level 2 default for all others FSBS 140mg/dL after insulin dose = move to next level *do not adjust corrective level UP at bedtime FSBS 80mg/dL = move back a level FSBS 40mg/dL = move back 2 levels Adjust X and Y together! Do not make adjustments if Endocrine or Glucose Management Services is seeing the patient

22 Nurses can adjust the basal Insulin! detemir 8 units subcutaneous at bedtime (default) AM FSBS 140mg/dL - 170mg/dL = Increase 10% AM FSBS greater than 170mg/dL = Increase 20% AM FSBS less than 80mg/dL = Decrease 10% Do not make adjustments if Endocrine or Glucose Management Services is seeing the patient Basal insulin tells us if the pancreas is keeping up with the sugar from the liver.

23 NPH & Mixed Insulins Patients receiving NPH or mixed insulins (Novolin 70/30 or Humalog 75/25) require extra attention when it comes to adding corrective and nutritional insulin. Since these patients are often confusing and their blood glucose difficult to control, please allow Glucose Management Services and/or the physician/pa/aprn to assist with insulin ordering and adjustment if needed.

24 How to Place an Order for the HMP

25 How to Adjust Levels/Doses in EMR Find order in patient s chart and right click *order will be under medications, not plans Communication type is protocol with cosign When adjusting doses, don t forget the PRN nutritional dose (Y) for snacks! Do not make adjustments if Endocrine or Glucose Management Services is seeing the patient

26 Does 1 unit really make a difference? YES! Patients have different levels of resistance or sensitivity to insulin doses. The corrective factor (X) is an indicator of the patient s sensitivity to insulin. Patients who are receiving large doses of corticosteroids or parenteral nutrition often have a sensitivity factor of 5, meaning that every 1 unit of insulin will only lower their blood sugar by 5 points. On the other hand, some patients with type 1 DM often have a sensitivity factor of 50, which means every 1 unit of insulin will lower their blood sugar by 50 points. So, you can see that one unit of insulin can make a big difference, especially in patients who are very insulin sensitive! (Merrill & Kester, 2007)

27 References Joint Commission (2014). Certification Programs. Retrieved from Merrill, A. & Kester, R. (2007). Hyperglycemia Hype, Volume 2.