Health Professions ActRevised Hypoglycemia ProtocolInsulin Subcutaneous Sliding Scale

Anar Dossa BScPharm CDESeptember 14, 2007

HPA-Health Professions ActWhat is it?Regulatory framework for health professionalsBasic requirements for regulating every health profession are similarAccountability for standards of practiceQuality assurance measurementsRigorous registration processMechanism to review public concerns

HPA-Health Professions ActNursing ImplicationsIncrease in scope of practice for registered nurses effective July 1, 2006Allows registered nurses to initiate certain patient care activities without a doctors order

WITHIN SCOPEOUT OFSCOPECRNBC CERTIFIED PRACTICEHPA-RN Scope of Practice

Nursing practice activities

Vital signsReserved actions without an order

Hypoglycemia:initiate IV access & medicationsReserved actions with an orderReserved actions for CRNBC certified practiceReserved actions outside scope of practiceNot reserved actionsCurrent PracticeSection 8July 1, 2006Section 9July 1, 2006Section 10August 2007NP & Delegated FnCRNBC Standards, Limits & Conditions crnbc 2006

Controls on PracticeCRNBC 2006

Provincial Pilots

VCH: Hypoglycemia, Wound Care, IV, Tylenol, Oxygen,CatheterIHA: Venipuncture initiationNHA: Catheter initiationVIHA: Oxygen initiationFHWound Care

Hypoglycemia ProtocolHypoglycemia is defined as blood sugar less than

Hypoglycemia ProtocolRisk factors for hypoglycemiaNutritional statusMissed meals, delayed mealsHeart failure, renal or liver diseaseMalignancySudden reduction of steroid doseAltered ability of patient to report symptomsVomiting

Hypoglycemia ProtocolRisk factors for hypoglycemiaNew NPO statusReduction in IV dextroseUnexpected interruption of feeds/TPNAltered consciousness from anesthesiaAdvanced agePrevious history of severe hypoglycemia

SymptomsVariable from patient to patientAssess patient for his/her individual symptoms

SymptomsTremblingPalpitationsSweatingAnxietyNauseaHungerTingling

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

SymptomsConfusionDifficulty concentratingWeaknessDrowsinessVision changesDifficulty speakingHeadacheDizzinessTiredness

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

SymptomsNightCrying outNight sweatsMorning headacheNightmares

Symptoms-severe

UnresponsiveUnconsciousComaSeizure

Hypoglycemia UnawarenessNo warning signalsFirst sign may be loss of consciousnessConfusion

Hypoglycemia in the ElderlyReduced release of epinephrine and glucagonCognitive impairmentMay not be able to communicate in timely manner

Beta-blockers and HypoglycemiaWhat is the concern?Not an absolute contraindication

Hypoglycemia ProtocolSection AConscious and able to swallowSection BConscious but NPO or unable to swallowTube fed/TPNSection CUnresponsive, unconscious, seizuring

Where will these items be kept?D10WStores item, units to order via storesD50WOmnicell machineGlucagonOmnicell machineDextrosolStores item

NIA Section 8: Hypoglycemia

4.bin

5.bin

6.bin

14.bin

8.bin

9.bin

10.bin

11.bin

12.bin

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

Insulin Subcutaneous Sliding ScaleRefer to pre-printed order

When should an insulin sliding scale be used?Supplement regularly scheduled insulin or oral diabetes medicationsMay be used as a dose finding strategyGoal is to use as little sliding scale insulin as possible

When should this sliding scale not be used?Diabetic ketoacidosisIntravenous insulin

Scheduled insulin plusSupplemental insulinCorrection-dose insulinDose-finding strategyAccommodate rapid changes in insulin requirementsIf correction doses are frequently required, change scheduled dose

Insulin Sliding Scale

Which sliding scale?LowIntermediateHighCustom

LowLow or unknown insulin resistanceHigh or unknown insulin sensitivityHow do you determine this?

Insulin Resistance Determination

Insulin Dose(Total Daily Dose)Resistance Level< 0.5 units/kgLow0.5 1 unit/kgIntermediate> 1 unit/kgHigh

Low ResistanceThinNPORenal FailureElderly

High ResistanceObese

Insulin Sliding ScaleAlways use regular insulinDo not give at hsWhy?Exception See protocol

Follow UpEvaluate total dose q24-48hrsDoes the basic dose need to be adjusted?

New Insulins on FormularyInsulin AspartNovoRapidRapid acting insulin analogueBolus insulinInsulin GlargineLantusLong acting insulin analogueBasal insulin

Insulin AspartMust be given immediately prior to mealsWithin 15 minutesRisk of hypoglycemia if meal is delayed Can be mixed with NPH as long as the manufacturer is the sameInject immediately after mixingCannot be given IV

Insulin GlargineCannot be given IVClear solutionDo not confuse with regular or aspartCannot be mixed with anything

Formulary StatusBoth insulins are restricted EndocrinologyFor Type 1 patients who experience hypoglycemia or inadequate control on Regular/NPHFor patients on these insulins prior to admission

Action Profiles of Bolus & Basal InsulinsPlasma Insulin levelsHoursNote: action curves are approximations for illustrative purposes. Actual patient response will vary.regular 6-10 hours NPH 1220 hours lispro/aspart 46 hours BASAL INSULINS

detemir ~ 6-23 hours (dose dependant)glargine ~ 20-26 hoursMayfield, JA.. et al, Amer. Fam. Phys.; Aug. 2004, 70(3): 491 Plank, J. et.al. Diabetes Care, May 2005; 28(5): 1107-12 BOLUS INSULINS

Insulin Comparison*minutes **special authority

InsulinOnset(hrs)Peak(hrs)Durn(hrs)Costper mLPcareCovgeAspart5-15*1-23-5$2.30PartialRegular0.5-12-46-8$1.24YesNPH1-26-1218-24$1.24YesGlargine2-4No peak20-24$5.51SA**

Insulin MixingRegular and NPHOK to mixResuspend NPHInject adequate amount of air into NPHWithdraw regular into syringe firstThen withdraw NPHWhat if you dont do it this way?

Questions?