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					    History at Georgetown Univ.
               Hospital
• SSI was standard of care

• Sentinel Event Occurred due to lack of
  basal insulin

• P.T. Committee requested study
  – Iatrogenic DKA common
  – High rate of errors in insulin orders
Post-op Order
    Protocol Implementation
• Champion
• Multi-disciplinary team
• Administration support
• Pharmacy & therapeutics committee
  approval
• Forms (orders, flowsheet, med kardex)
• Education:
  nursing, pharmacy, physicians & NP/PA
• Monitoring/Quality Assurance
         Education:
Core knowledge for physicians
• Impact of BG on hospital outcomes
• Hospital targets for BG
• Terminology
  basal/nutritional/correction
• Insulins
• Hypoglycemia prevention & treatment
• Avoid SSI
• Special circumstances
         Education:
 Core competency for Nurses
• Bedside glucose monitoring
  technique
• Critical and target BG values
• Insulin administration technique
• Optimum timing of SQ insulin shots
• Hypoglycemia prevention &
  treatment
• BG & insulin dose documentation
• When to call the MD
          Patient Education:
            Content areas
•   What is diabetes?
•   Symptoms & signs of high and low BG
•   Hypoglycemia Rx
•   Medications (specifics of discharge regimen)
•   Self-glucose monitoring (keep a log)
•   When to call the doctor
•   Education resources
       Adapted from American Association of Diabetes Educators
                  Survival Skills Education Guidelines.
         GU Hospital Initiatives
             2004 - 2006
• In-service all M.D.’s and nursing units on proper
  basal/bolus insulin therapy

• Laminated cards

• I.V. Drip changes and any SC insulin injection
  requires second nurse check dose and sign

• Implement IV insulin protocol outside of ICU
        GU Hospital Initiatives
         (cont) 2004 - 2006
• Piloted standard order form and MAR for
  s.q. insulin administration

• Eliminated Regular insulin except for
  enteral feeding and insulin drips

• Roll out of revised order form for entire
  hospital (July ’05.)
Components of the standardized
 subcutaneous insulin protocol
• BG monitoring frequency
• Target BG range
•   Programmed insulin orders:
•   Suggested lag times for prandial insulin
•   Correction dose algorithm
•   Call parameters for high & low BG
•   Hypoglycemia Rx guidelines or reference to
    hypo protocol
Insulin-Glucose Flow Sheet
Prevention/Tx of Hypoglycemia
• Proactive Approach
  – Missed meal, tube feeding D/C’d
  – Schedule procedures in the AM

• Establish a nurse-driven protocol for starting
  dextrose and test hourly glucose testing if
  hypoglycemia anticipated.
                GU Hospital Results
                 Insulin Error Rate
           35
           30

           25
           20
% Errors
           15
           10

           5
           0
                    2005        2006
      Georgetown Univ. Hospital
   Frequency of BG tests over Time
            90
            80
             70
# Bedside BG 60
     tests   50
 (thousands) 40
            30
            20
            10
             0
                  Jan-Jun'05   July-Dec '05   Jan-May'06
           Georgetown Univ. Hospital
             BG Levels over Time
             60

             50

             40
% of BG tests
in specified 30                                        Jan-June '05
    range                                              July-Dec '05
              20
                                                       Jan-May'06
             10

              0
                   0 - 79       80 - 180       > 180
                            BG range (mg/dl)
        TEAM APPROACH TO THE TREATMENT
       OF THE HOSPITALIZED DIABETIC PATIENT


                  Physician
                                 Nurse Educator




                                                  Dietitian

Endocrinologist
                              Pharmacist

				
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posted:2/24/2012
language:English
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