HFHS Orientation - Adult GPU Glycemic Protocol PDF

# Examples of prandial insulins - lispro (Humalog) - regular insulin (Novolin R) # Correctional insulin - Short acting insulin given for hyperglycemia measured before the meal. # Insulin Sensitive - Patients who have had a single blood glucose below 70 mg/dL or have the following chronic health c...

# Examples of prandial insulins - lispro (Humalog) - regular insulin (Novolin R) # Correctional insulin - Short acting insulin given for hyperglycemia measured before the meal. # Insulin Sensitive - Patients who have had a single blood glucose below 70 mg/dL or have the following chronic health conditions: - Kidney failure with a creatinine greater than 2 - Liver failure - Patient 70 years old or older - Adult patients less than 50 kg - Patients with erratic eating habits - Insufficiently treated patients with Addison's disease or other endocrinologic glandular failure # Hypoglycemia - A blood glucose less than 70 mg/dL that are associated with the following symptoms: - Change in mental status (difficult concentrating, incoordination, weakness, lethargy, blurred vision, confusion) - Sweating - Anxiety - Palpitations - Hunger - Tremor # Policy - This protocol is intended for non ICU patients with diabetes or patients without diabetes who may develop hyperglycemia secondary to medical or surgical reasons. - This protocol allows the provider to use either a short term correctional insulin approach (less than 48 hours) OR a longer term, "Basal-Prandial" approach to normalize the blood glucose. - This protocol assumes the concomitant use of basal AND prandial insulin. - The pre meal blood glucose goal is less than 140 mg/dL. - All blood glucoses less than 70 mg/dL should be treated with the Hypoglycemic Protocol within this policy and patients placed on the 'Insulin Sensitive/Low dose' scale. # Exclusion Criteria - Patients in diabetic ketoacidosis - Pancreas transplant patients: Glycemic assessment before the use of a protocol is necessary for recognition of rejection. The Transplant Team Providers will decide if the protocol is to be used # Protocol - Using the GPU Glycemic Control - Subcutaneous insulin electronic order set, the provider will order a basal insulin dose, prandial insulin dose, initial correctional insulin level, and the initial schedule for blood glucose testing. - Based on the patient's blood glucose results, the initial insulin level and initial schedule, the RN will administer the appropriate correctional dose of lispro insulin based on the correctional insulin dosing scale ordered by the provider. Correctional and prandial insulin will be given together. - All insulin doses will be given subcutaneously. - All patients on the protocol will have a Glycated Hemoglobin (Hemoglobin A1C) measured. - All patients with End Stage Renal Disease (ESRD) requiring glycemic control will be started on the insulin sensitive/Low dose level and remain on this level unless directed by the provider. - Patient who are receiving meals or who have bolus tube feedings will have their blood glucoses checked before meals (or bolus) and at bedtime. - Patient who are NPO, on TPN, or have continuous tube feeding will have their blood glucose checked every 6 hours (06, 12, 18, and 24). - Patients who are receiving cyclic tube feedings overnight but do not receive meals during the day, will have their blood glucose checked every 6 hours (06,12,18,24). For patients who are receiving cyclic tube feedings over night but are also receiving meals during the day will have their blood glucoses checked before meals and at bedtime. - Patient will have their blood glucose checked only with the hospital's glucometer. - All blood glucose results and insulin doses will be documented in the electronic health record (EHR) - For provider dosing guidelines see Appendix A - Patients on "high dose" correctional scale AND basal insulin that have more than 2 blood glucoses greater than 200 mg/dL, collaborate with provider for an endocrinology consult # The Correctional Insulin Dosing Method - Correctional insulin dosing may be used along with basal-prandial-insulin dosing or as a means to assess the glycemic burden. - Examples of assessing the glycemic burden include: - patients receiving oral hypoglycemics who may require occasional correctional insulin - post operative glycemic control - assessing the glycemic burden in a patient with undiagnosed diabetes - The provider will order the initial Glycemic Control Level under Correctional Insulin using the electronic order set in the EHR. The provider will also have the option to order a patient specific correctional insulin dosing scale. - Lispro insulin is the suggested insulin of choice for correctional insulin dosing. Regular insulin can be used, but must be ordered outside of the protocol order set. # Correction Insulin Dosing Scale | Blood Glucose Level mg/dL | Insulin Sensitive/ Low dose | Moderate dose | High dose | Bedtime or midnight coverage * | |---|---|---|---|---| | Less than 70 | Begin Hypoglycemic Protocol AND Call Provider | | | | | 70-140 | 0 units | 0 units | 0 units | 0 units | | 141-180 | 1 units | 2 units | 3 units | 0 units | | 181-220 | 2 units | 4 units | 6 units | 0 units | | 221-260 | 3 units | 6 units | 9 units | 0 units | | 261-300 | 4 units | 8 units | 12 units | 4 units | | 301-340 | 5 units | 10 units | 15 units | 4 units | | 341-400 | 6 units | 12 units | 18 units | 4 units | | Over 400 | Call Provider | | | | * Maximum insulin dose for bedtime and/or midnight coverage is 4 units unless the patient is receiving continuous or cyclic enteral feedings. If on continuous or cyclic enteral feedings the midnight glucose will be covered with the same glycemic control level as the previous check. # Prandial Insulin - Prandial insulin will be given within 10 minutes of a meal (pre- or post-meal) - Correctional and prandial insulin will be given together. - Hold prandial insulin for a pre-meal glucose of less than 70 mg/dL, notify provider, and begin hypoglycemic treatment # Nutritional and NPO considerations - **Total Parenteral Nutrition Patients (TPN)** - All insulin added to the TPN will be managed by the provider responsible for TPNs at their institution. - **Continuous Tube Feeding Patients** - receiving continuous tube feeding can be prescribed basal and correctional insulin. Prandial insulin will not be used but scheduled regular insulin may be prescribed. - **Cyclic Tube Feeding Patients** - who are receiving cyclic tube feeding can be prescribed basal and correctional insulin. If a cyclic tube feeding is pleasure eating meals throughout the day they may also require prandial coverage. - **Bolus Tube Feeding** - Patients receiving intermittent tube feeding boluses can be prescribed basal, prandial, and correctional insulin doses. - **Nothing by mouth (NPO)** - Follow NPO grid. - Continue scheduled blood glucose checks. - All patients should be on 'Insulin sensitive/Low dose' scale while NPO. - Once the patient is eating, collaborate with the provider to resume to the previous level. # Insulin Order: All Patients who are NPO for Tests or Procedures | Insulin Order | Action | Time For Action | |---|---|---| | Correctional Insulin Only | Decrease to the insulin 'sensitive level' | As soon as patient is NPO | | Receiving Basal Insulin Only | Give 50% glargine, detemir or NPH dose <br> If continuous tube feedings are stopped hold all basal insulin <br> For Type I diabetes give 100% of dose | With Next Dose | | Receiving Basal AND Prandial insulin | Hold all prandial insulin doses<br> Continue with full glargine or detemir insulin dose<br> Give 50% of am NPH dose and 100% of pm NPH dose | With Next Dose | | Receiving Prandial Only | Hold Prandial Insulin | With Next Dose | # Meal Type: All Patients who are NPO for Tests or Procedures | Meal type | Action | Time For Action | |---|---|---| | Receiving bolus tube feedings and made NPO | Decrease correctional insulin to the Insulin sensitive/ Low dose scale <br> Stop prandial insulin, but continue correctional insulin <br> Give 50% of the basal dose UNLESS Type 1 diabetes, then give 100% of basal dose | As soon as patient is NPO | | Continuous or cyclic tube feedings are stopped | Hold basal insulin (glargine, detemir, NPH) UNLESS Type I Diabetes, then give 50% of dose and notify the provider | As soon as tube feedings are stopped | #KEY POINT: Whenever a patient is placed on the insulin sensitive/low dose scale the patient will remain on the insulin sensitive/low dose scale until provider places an order to advance. # For HFH, HFMH, HFWBH, HFWH, HFJH - Hypoglycemia Treatment: for glucose less than 70 mg/dL | Blood Glucose Level mg/dl | Patient Responsive and able to swallow or take meds via gastric tube | Patient unresponsive with IV access | Patient unresponsive NO IV access | |---|---|---|---| | 41-69 | 4 oz of juice <br> OR <br> Instant Glucose 37.5 gm (1 tube) <br> Treat patient immediately | Dextrose 50% 25 mL IV x1 <br> Treat patient immediately | Glucagon 1 mg IM once <br> Call rapid response team and physician to obtain IV access <br> Treat patient immediately | | 40 or less | Dextrose 50% 50 mL IV x1 <br> OR <br> 8 oz of juice (if patient has gastric tube) or 75 gm (2 tubes) Instant Glucose <br> If patient has no IV access: <br> 8 oz of juice <br> OR <br> Instant Glucose 75 gm (2 tubes) <br> Confirm blood glucose with a second sample on same machine and/or send sample to lab stat. | Dextrose 50% 50 mL IV x1 <br> AND <br> 8 oz of juice (if patient has gastric tube) or 75 gm (2 tubes) Instant Glucose <br> Confirm blood glucose with a second sample on same machine and/or send sample to lab stat. | Glucagon 1 mg IM once <br> AND <br> Call rapid response team and physician to obtain IV access <br> AND <br> 8 oz of juice (if patient has gastric tube) or 75 gm (2 tubes) Instant Glucose <br> Confirm blood glucose with a second sample on same machine and/or send sample to lab stat. | Recheck Blood Glucose 15 minutes and 1 hour after treatment given. For Glucose less than 70 mg/dL notify provider and: - Decrease correctional insulin level to Insulin sensitive/Low Dose scale - Hold all prandial insulin (lispro or regular insulin) - Notify provider for dose adjustment of basal insulin (NPH, glargine, or detemir) # For Kingswood and Maplegrove Hospital - Hypoglycemia Treatment: for glucose less than 70 mg/dL | Blood Glucose Level mg/dl | Patient Responsive and Able to Swallow | Patient Unresponsive or Unable to Swallow | |---|---|---| | 41-69 | 4 oz of juice <br> OR <br> Instant Glucose 37.5 gm (1 tube) | Glucagon 1 mg IM once | | 40 or less | OR <br> Instant Glucose 37.5 gm (1 tube) <br> Call physician and 911 (siren specified) <br> 8 oz of juice <br> OR <br> Instant Glucose 75 gm (2 tubes) <br> Confirm blood glucose with a second sample on same glucometer. | If Unresponsive -Call physician and 911 <br> Call physician and 911 (siren specified) <br> Glucagon 1 mg IM once <br> Confirm blood glucose with a second sample on same glucometer. | Recheck Blood Glucose 15 minutes and 1 hour after treatment given For Glucose less than 70 mg/dL notify provider and: - Decrease correctional insulin level to Insulin sensitive/Low dose level - Hold all prandial insulin (lispro or regular insulin) for glucose less than 70 mg/dl - Notify provider for dose adjustment of basal insulin (NPH, glargine, or detemir) # Glucose Monitoring Points - If the patient's glucometer blood glucose is greater than 400 mg/dL or less than 50 mg/dL a second sample must verify result with the same meter within 5 minutes. Notify Provider if the glucose is greater than 400 mg/dL or less than 50 mg/dL. - If glucose is less than 140 mg/dL for 24 hours without insulin, blood glucoses are to be checked daily with labs. The higher frequency of blood glucose measurements should be resumed in patients who are at risk for elevated glucoses, such as those undergoing surgery or receiving medications that can cause elevated blood glucose measurements (e.g. glucocorticoids). - Glucometer blood glucose readings will be inaccurate, and serum blood glucose readings are preferred for patients with impaired peripheral circulation due to severe hypotension with systolic blood pressure <75mmHg - Glucometer blood glucose readings will be inaccurate and serum blood glucose readings are preferred for patients with the following interfering substances: - Intravenous N-Acetylcysteine - Intravenous Vitamin C at doses of 1000 mg or higher - Hypertriglyceridemia (>1800 mg/dl) # Related Documents - Tier 3: HFWB Progressive Care Unit (PCU) Adult Glycemic Control with IV Insulin