SHINE Study PowerChart Order Set CONTROL

Transcription

1 SHINE Study PowerChart Order Set CONTROL Orders Patient Care Component Blood Glucose Details Hypoglycemia: For BG <80mg/dl stop all IV infusions and hold all subcutaneous injections. Check finger stick point of care glucose every 15 minutes until glucose is 80mg/dL. You may open the full protocol on the SHINE laptop. Additional steps for BG <70mg/dl send a STAT laboratory serum glucose and screen the patient for hypoglycemia symptoms using Hypoglycemia Symptomatic Questionnaire (Completed every 15 min when BG <70mg/dl) and perform Q15 min Neuro Checks until glucose is 80mg/dL. PAGE Dr. Wold to advise of Hypoglycemia. Once glucose is 80 mg/dl: Restart IV & SQ insulin or saline per protocol and complete one final Hypoglycemia Symptomatic Questionnaire. Patients should NOT consume additional food NOT included on the meal tray from the hospital kitchen. Family, friends and visitors should be instructed not to bring in food or drinks for the patient or to consume food from the patient s trays unless approved by the nurses, after patients finish eating. When treatment is temporarily interrupted for any reason (e.g. patient needing to go off the care unit and the clinical nurse cannot accompany the patient to maintain the SHINE study procedures) The IV saline drip should be stopped. Upon return to the unit, if glucose checks or subcutaneous insulin injections were not missed, maintain schedule for sliding scale checks and dosing. Resume saline infusion at the next scheduled glucose check. If glucose checks or subcutaneous insulin injections were missed, the following procedures should be followed: Immediately check the finger stick glucose upon return to the unit and resume the saline infusion according to the sliding scale. If one of the time points for scheduled subcutaneous injections was missed, use the result of the glucose check and sliding scale to determine if a SQ insulin dose is indicated and give injection immediately. Do not give SQ regular insulin injections <3 hours apart. If a subcutaneous injection is given upon return to the unit (as described) AND the next scheduled injection is <3 hours do not give insulin at the next scheduled injection time. Return to schedule for glucose checks and subcutaneous insulin injections. Do not check glucose levels <1 hour apart. Frequency: Q1Hr Duration: 4 Special Instructions: All testing must be done as a finger stick (No ART/Central Lines)

2 Blood Glucose Frequency: Q3Hr Duration: 66 Special Instructions: Time testing for 0300, 0600, 0900, 1200, 1500, 1800, 2100, MEAL TIME MATTERS: Ideally pt will be NPO 2Hrs prior to testing. o Breakfast as close to 7am as possible o Lunch after the 1200 check o Dinner after the 1800 check You have 15 min on either side of the testing window; use this to help with timing. All testing must be done as a finger stick (No ART/Central Line samples). Document results in both the SHINE laptop and PowerChart. Nutrition Svcs Diabetic Diet Special Instructions: 60 gram carbohydrate diet for breakfast, lunch and dinner. Medications Insulin Regular Insulin Dose: Per LEVEL 1 Sliding Scale on SHINE Study Laptop Insulin Regular Insulin Dose: Per LEVEL 2 Sliding Scale on SHINE Study Laptop Duration: 48 Insulin Regular Insulin Dose: Per LEVEL 3 Sliding Scale on SHINE Study Laptop Duration: 24 Insulin Lantus (Glargine) Insulin Dose: Calculate per instructions Frequency: Once Special Instructions: For Level 3, give a one time subcutaneous basal insulin injection at a dose of 40% of previous 24 hours entire insulin dose. This dose of basal insulin should be given approximately at the 48 hour point regardless of time of day.

3 Dextrose 50% in water (D50W) Volume dose: 25 Volume dose unit: ml Route of administration: IV Frequency: As Directed PRN: Yes PRN Reason: Hypoglycemia Special Instructions: A dose of IV D50 25 ml (1/2 amp) will be given (slow IV push over 1 2 minutes) every 15 minutes until blood glucose is 80 mg/dl. Repeat finger stick glucose checks and treatment every 15 minutes if needed until glucose is 80 mg/dl.

4 SHINE Study PowerChart Order Set INTERVENTION Component Details Orders Hypoglycemia: For BG <80mg/dl stop all IV infusions and hold all subcutaneous injections. Check finger stick point of care glucose every 15 minutes until glucose is 80mg/dL. GlucoStabilizer will guide you. Additional steps for BG <70mg/dl send a STAT laboratory serum glucose and screen the patient for hypoglycemia symptoms using Hypoglycemia Symptomatic Questionnaire (Completed every 15 min when BG <70mg/dl) and perform Q15 min Neuro Checks until glucose is 80mg/dL. PAGE Dr. Wold to advise of Hypoglycemia. Once glucose is 80 mg/dl: Restart IV & SQ insulin or saline per protocol and complete one final Hypoglycemia Symptomatic Questionnaire. Patients should NOT consume additional food NOT included on the meal tray from the hospital kitchen. Family, friends and visitors should be instructed not to bring in food or drinks for the patient or to consume food from the patient s trays unless approved by the nurses, after patients finish eating. When treatment is temporarily interrupted for any reason (e.g. patient needing to go off the care unit and the clinical nurse cannot accompany the patient to maintain the SHINE study procedures) The IV insulin drip should be stopped. Upon return to the unit, the finger stick point of care glucose should be checked immediately. If the IV insulin infusion has been off for <3 hours select Resume in GlucoStabilizer. If the IV insulin infusion has been off for 3 hours, select Start a New Drip in GlucoStabilizer. Patient Care Blood Glucose Frequency: None Special Instructions: Q1 2 Hrs as determined by the GlucoStabilizer tool on SHINE Study Laptop. All testing must be done as a finger stick (No ART/Central Lines) Document results in both the GlucoStabilizer and PowerChart. Nutrition Svcs Diabetic Diet Special Instructions: 60 gram carbohydrate diet for breakfast, lunch and dinner. Medications Insulin Aspart (Novolog) Insulin Dose: Per GlucoStabilizer Frequency: AC Special Instructions: Give Insulin within 20 minutes after starting each of the three daily meals (breakfast, lunch and dinner. Twenty minutes into the meal assess meal consumption or likely consumption. NO consumption (0 grams carbohydrates) o If no, or nearly no, consumption then meal insulin is not required. DO NOT give SQ insulin and do not enter this into GlucoStabilizer. Partial Consumption (30 grams carbohydrates)

5 Full or Partly Full Consumption (60 grams carbohydrates) o Use the Cover Carbs option in GlucoStabilizer, entering either 30 or 60 for Grams of Carbohydrates Eaten follow GlucoStabilizer for dosing. Saline Dextrose 50% in water (D50W) Dose: 5 units Frequency: BID (0900, 2100) Special Instructions: NPO or Continuous Tube Feeds The subcutaneous saline injections are needed to maintain the blind and simulate the 0 4 subcutaneous insulin injections in the control group. You may use sterile saline from a 10mL flush. Please prepare this in the med room to maintain the blind. Volume dose: Per GlucoStabilizer Volume dose unit: ml Route of administration: IV Frequency: As Directed PRN: Yes PRN Reason: Hypoglycemia Special Instructions: An individualized dose of IV D50 will be given (slow IV push over 1 2 minutes). The specific dose will be determined by GlucoStabilizer based on the glucose concentration. Recheck blood glucose every 15 minutes as directed by the decision support tool. Repeat treatment every 15 minutes as directed by the decision support tool until glucose is 80 mg/dl.