timing of insulin administration
TRANSCRIPT
Lehigh Valley Health NetworkLVHN Scholarly Works
Patient Care Services / Nursing
Timing of Insulin AdministrationZeena Bacchus BSN, RNLehigh Valley Health Network
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Published In/Presented AtBacchus, Z. (2014, June 5). Timing of Insulin Administration. Poster presented at LVHN UHC/ACCN Nurse Residency ProgramGraduation, Lehigh Valley Health Network, Allentown, PA.
Zeena Bacchus, RN, BSN
Timing of Insulin
Administration
Background/Significance
Glucose control affects the recovery process of hospitalized patients
Rapid acting insulin administration in a timely manner can help control diabetic patients blood sugars and decrease the length of stay in the hospital
Although LVHN has developed protocols and interventions to help with insulin administration, there are still high numbers of patients not receiving insulin in a timely manner
Episodes of hypoglycemia occur with significant risks to diabetic patients
PICO Question
In adult diabetics on PCU requiring timely rapid acting insulin, will multifactorial interventions (educating, communicating, and visual cues) compared to current practice result in fewer hypoglycemic episodes and staff satisfaction?
P: Inpatient adult diabetics
I: Specific visual cues
C: Current practice versus new implementation
O: Fewer hypoglycemic episodes, staff satisfaction
Problem Focused Trigger
On PCU, the diabetic educator relayed that
there were various trends in timing and
administration of insulin which can cause
hypoglycemic reactions.
Evidence
▪ EBSCO and CINAHL were the search engines utilized
▪ Keywords used were: rapid acting insulin, rapid acting insulin and timing
▪ Evidence was reviewed and synthesized from six different research articles and analysis of some patients receiving humalog
▪ Many research articles admit that timing of administration of rapid acting insulin is problematic. Many articles suggest that increasing communication, standardizing meal deliveries, and decreasing the workload of a RN can play a vital role in helping to improve adequate timing
Evidence
▪ “Many methods have been applied to improve the timing of insulin
administration… including nurse page alerts, equal distribution of diabetic patients among nursing assignments, meal times posted in patient rooms, signs on the doors of patients scheduled to receive insulin, engagement of dietary personnel and patients, and nursing education programs” (Houck, Tirumalasetty & Meadow, 2013).
▪ “The intervention highlighted the importance of appropriate timing of blood
glucose monitoring and insulin administration in relation to mealtimes, mimicking as closely as possible the normal insulin response by the pancreas linked to improved clinical outcomes” (Houck, Tirumalasetty & Meadow, 2013).
▪ “Lack of communication and training were believed to be the two factors
that contributed to errors most frequently” (Golightly, Jones, Hamamura, Stolpman, McDermott, 2006).
▪ “Nurse workload could affect the ability to carry out and coordinate care in
a timely way” (Barbara, F., Barbara, B., & Maureen, A, 2011).
▪ _
Evidence ▪ “Standardizing food delivery schedules and utilizing scorecards to track
on-time meal deliveries to the floor enabled nursing to more accurately administer insulin in coordination with the delivery of meals” (Yamamoto, J. J., & Malatestinic, B., & Lehman, A., & Juneja, R., 2010).
▪ “Increasing communication and restricting the scheduling of inpatient procedures during meal times reduced disruptions to insulin administration” (Yamamoto, J. J., & Malatestinic, B., & Lehman, A., & Juneja, R., 2010).
▪ “Engaging dietary personnel and patients in ensuring timely administration of premeal rapid acting insulin (RAI) with use of a sign indicating the need for insulin administration resulted in significant improvements” (Donihi, A.C., & Abriola, C. & Hall, R. & Korytkowski, M.T., 2010).
Current Practice at LVHN
Hypoglycemia and Hyperglycemia Clinical Practice Guidelines
▪ Hypoglycemia Algorithm
Carb coverage magnets
Implementation 1. Process Indicators and Outcomes
POC timing and Insulin ISF administration coverage timing
2. Baseline Data
Weekly Point of Care Blood Glucose Detail Report displayed that less
than 70% of time BG were within range (70-180)
3. Design (EBP) Guideline(s)/Process
Data was collected on the timing of POC and the timing of Insulin coverage to determine if it was given within 30 minutes
Implementation (Cont.)
4. Implemented EBP on Pilot Units Implemented on PCU night shift Communication between technical partner and RN In-service staff on Insulin Administration Policy Pilot study conducted from 04/07-04/14
5. Evaluation (Post data) of Process & Outcomes 62% of patient blood glucose received insulin in a timely manner or did not require coverage
6. Modifications to the Practice Guideline No modifications at this time
7. Network Implementation None at this time
Practice Change
This EBP was done to continue to bring
awareness on PCU of timing and administration
of rapid acting insulin in order to have tighter
glucose control and improve patient’s overall
health. The continuation of raising awareness and
placing visual cues at each pod as a reminder to
RNs will be implemented.
Results
▪ There were a total of 87 Blood Glucose
collected with POC time and Insulin
Administration timing: 37.7% did not receive rapid acting insulin within 30 minutes
62% received insulin in a timely manner or did not require
coverage
▪ Next steps: Continue to monitor
Implications for LVHN
Improve glycemic control by decreasing
hypoglycemia
Improve clinical outcomes and recovery process
Decrease cost
Strategic Dissemination of
Results
■ PLAN for DISSEMINATION
Lessons Learned
It was difficult to spread the work during night shift since many of the staff were float RNs or technical partners.
RNs were receptive that this is an issue but agreed that high workload demand played a critical factor.
All RNs that were re-educated knew the timing of rapid acting insulin.
References American Diabetes Association. (2004). Diabetes Care: Insulin Administration, 27 doi: 10.2337/diacare.27.2007.S106 Donihi, A.C., & Abriola, C. & Hall, R. & Korytkowski, M.T. (2010). Getting the Timing Right in the Hospital: Synching Insulin Administration with Meal Tray Arrival. American Diabetes Association 70th Scientific Sessions. Retrieved from http://professional.diabetes.org/Abstracts_Display.aspx?TYP=1&CID=79965. Barbara, F., Barbara, B., & Maureen, A. (2011). Nursing practice patterns: Timing of insulin administration and glucose monitoring in the hospital. The Diabetes Educator, 37, 357-362 Houck, P., Tirumalasetty, N., & Meadow, R. (2013). Insulin administration and meal delivery coordination for hospitalized patients. The Ochsner Journal, 327-333. Retrieved from http://europepmc.org/articles/PMC3776507/reload=0;jsessionid =Rsf6RmeTUClB5sPwI2VI.8 Golightly, L. K., Jones, M. A., Hamamura, D. H., Stolpman, N. M. and McDermott, M. T. (2006), Management of Diabetes Mellitus in Hospitalized Patients: Efficiency and Effectiveness of Sliding- Scale Insulin Therapy. Pharmacotherapy, 26: 1421–1432. doi: 10.1592/phco.26.10.1421 Yamamoto, J. J., & Malatestinic, B., & Lehman, A., & Juneja, R. (2010). Facilitating Process Changes in Meal Delivery and Radiological Testing to Improve Inpatient Insulin Timing using Six Sigma Method. Quality Management in Health Care, 19(03), 189-200.
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