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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