Health Professions Act Revised Hypoglycemia Protocol Insulin Subcutaneous Sliding Scale

Anar Dossa BScPharm CDE September 14, 2007

HPA-Health Professions Act What is it?

Regulatory framework for health professionals Basic requirements for regulating every health profession are similar

Accountability for standards of practice Quality assurance measurements Rigorous registration process Mechanism to review public concerns

HPA-Health Professions Act Nursing Implications

Increase in scope of practice for registered nurses effective July 1, 2006 Allows registered nurses to initiate certain patient care activities without a doctors order

HPA-RN Scope of Practice

WITHIN SCOPE

CRNBC CERTIFIED PRACTICE OUT OF SCOPE

Nursing practice activities

Vital signs Not reserved actions Current Practice

Reserved actions Reserved Reserved without an order actions with actions for an order CRNBC certified Hypoglycemia: practice initiate IV access & medications

Reserved actions outside scope of practice

Section 8 July 1, 2006

NP & Section 9 Section 10 Delegated July 1, August Fn 2006 2007

CRNBC Standards, Limits & Conditions

crnbc 2006

Controls on Practice

CRNBC 2006

Provincial Pilots
VCH: IHA: NHA: VIHA: FH

Hypoglycemia, Wound Care, IV, Tylenol, Oxygen,Catheter Venipuncture initiation Catheter initiation Oxygen initiation Wound Care

Hypoglycemia Protocol

Hypoglycemia is defined as blood sugar less than

Hypoglycemia Protocol

Risk factors for hypoglycemia

Nutritional status

Missed meals, delayed meals

Heart failure, renal or liver disease Malignancy Sudden reduction of steroid dose Altered ability of patient to report symptoms Vomiting

Hypoglycemia Protocol

Risk factors for hypoglycemia

New NPO status Reduction in IV dextrose Unexpected interruption of feeds/TPN Altered consciousness from anesthesia Advanced age Previous history of severe hypoglycemia

Symptoms

Variable from patient to patient

Assess patient for his/her individual symptoms

Symptoms

Trembling Palpitations Sweating Anxiety Nausea Hunger Tingling

Clinical Practice Guidelines Can J Diabetes Dec 03 www.diabetes.ca

Symptoms

Confusion Difficulty concentrating Weakness Drowsiness Vision changes Difficulty speaking Headache Dizziness Tiredness Clinical Practice Guidelines Can J Diabetes Dec 03
www.diabetes.ca

Symptoms

Night

Crying out Night sweats Morning headache Nightmares

Symptoms-severe

Unresponsive Unconscious Coma Seizure

Hypoglycemia Unawareness

No warning signals First sign may be loss of consciousness Confusion

Hypoglycemia in the Elderly

Reduced release of epinephrine and glucagon Cognitive impairment

May not be able to communicate in timely manner

Beta-blockers and Hypoglycemia

What is the concern? Not an absolute contraindication

Hypoglycemia Protocol

Section A

Conscious and able to swallow Conscious but NPO or unable to swallow

Section B

Tube fed/TPN

Section C

Unresponsive, unconscious, seizuring

Where will these items be kept?

D10W

Stores item, units to order via stores

Omnicell machine Omnicell machine Stores item

D50W

Glucagon

Dextrosol

NIA Section 8: Hypoglycemia

Section 8 (1) Perform venipuncture for the purpose of: Establishing intravenous access, maintaining patency or managing hypoglycemia Administer a solution by instillation parenterally.

RN Assess Pt. Diagnose Condition

Condition:
Hypoglycemia Policy/Patient Care Guideline

Contraindications: PCG

Nurse Initiated Activity:

Document Assessment Initiate Glucagon or IV insertion IV Solution

Contact Physician

Pharmacy: Processes NIA Records Glucagon or D50W on MAR

RN accountable to anticipate & monitior outcomes

Physician aware within 4 hrs

Follow Up

Why did hypoglycemia occur? Should the dose of insulin or oral agent be adjusted?

Insulin Subcutaneous Sliding Scale

Refer to pre-printed order

When should an insulin sliding scale be used?

Supplement

regularly scheduled insulin or oral diabetes medications

May

be used as a dose finding strategy

Goal

is to use as little sliding scale insulin as possible

When should this sliding scale not be used?

Diabetic ketoacidosis Intravenous insulin

Insulin Sliding Scale

Scheduled insulin plus Supplemental insulin

Correction-dose insulin Dose-finding strategy Accommodate rapid changes in insulin requirements If correction doses are frequently required, change scheduled dose

Which sliding scale?

Low Intermediate High Custom

Low

Low or unknown insulin resistance High or unknown insulin sensitivity

How do you determine this?

Insulin Resistance Determination

Insulin Dose (Total Daily Dose) < 0.5 units/kg 0.5 1 unit/kg Resistance Level Low Intermediate

> 1 unit/kg

High

Low Resistance

Thin NPO Renal Failure Elderly

High Resistance

Obese

Insulin Sliding Scale

Always use regular insulin Do not give at hs

Why? Exception

See protocol

Follow Up

Evaluate total dose q24-48hrs Does the basic dose need to be adjusted?

New Insulins on Formulary

Insulin Aspart

NovoRapid Rapid acting insulin analogue Bolus insulin

Lantus Long acting insulin analogue Basal insulin

Insulin Glargine

Insulin Aspart

Must be given immediately prior to meals

Within 15 minutes Risk of hypoglycemia if meal is delayed Can be mixed with NPH as long as the manufacturer is the same Inject immediately after mixing Cannot be given IV

Insulin Glargine

Cannot be given IV Clear solution

Do not confuse with regular or aspart

Cannot be mixed with anything

Formulary Status

Both insulins are restricted

Endocrinology

For Type 1 patients who experience hypoglycemia or inadequate control on Regular/NPH

For patients on these insulins prior to admission

Action Profiles of Bolus & Basal Insulins

lispro/aspart 46 hours regular 6-10 hours NPH 1220 hours detemir ~ 6-23 hours (dose dependant) glargine ~ 20-26 hours

BOLUS INSULINS BASAL INSULINS

Hours
Note: action curves are approximations for illustrative purposes. Actual patient response will vary.
Mayfield, JA.. et al, Amer. Fam. Phys.; Aug. 2004, 70(3): 491 Plank, J. et.al. Diabetes Care, May 2005; 28(5): 1107-12

Insulin Comparison
Insulin Onset Peak (hrs) (hrs) 5-15* 1-2 Durn (hrs) 3-5 6-8 18-24 20-24 Cost Pcare per mL Covge $2.30 Partial $1.24 $1.24 $5.51 Yes Yes SA**

Aspart

Regular 0.5-1 2-4 NPH 1-2 6-12 No peak

Glargine 2-4

*minutes **special authority

Insulin Mixing

Regular and NPH

OK to mix Resuspend NPH Inject adequate amount of air into NPH Withdraw regular into syringe first Then withdraw NPH What if you dont do it this way?

Questions?