insulin infusion protocol in the icu changing care…changing culture by: holly ann roush, rn, bsn,...

22
Insulin Infusion Insulin Infusion Protocol in the ICU Protocol in the ICU Changing Care…Changing Changing Care…Changing Culture Culture By: Holly Ann Roush, RN, By: Holly Ann Roush, RN, BSN, Nurse Clinician BSN, Nurse Clinician level IV level IV

Upload: mia-dunn

Post on 27-Mar-2015

216 views

Category:

Documents


4 download

TRANSCRIPT

Page 1: Insulin Infusion Protocol in the ICU Changing Care…Changing Culture By: Holly Ann Roush, RN, BSN, Nurse Clinician level IV

Insulin Infusion Protocol in Insulin Infusion Protocol in the ICUthe ICU

Changing Care…Changing Changing Care…Changing CultureCulture

By: Holly Ann Roush, RN, BSN, By: Holly Ann Roush, RN, BSN, Nurse Clinician level IVNurse Clinician level IV

Page 2: Insulin Infusion Protocol in the ICU Changing Care…Changing Culture By: Holly Ann Roush, RN, BSN, Nurse Clinician level IV

In the past…In the past…

What patients were placed on insulin What patients were placed on insulin infusions?infusions?

What did management of the patient entail?What did management of the patient entail? What nursing management was required?What nursing management was required? What were the positive points of the past What were the positive points of the past

management model?management model? What were the negative points of the model?What were the negative points of the model?

Page 3: Insulin Infusion Protocol in the ICU Changing Care…Changing Culture By: Holly Ann Roush, RN, BSN, Nurse Clinician level IV

What patients were placed What patients were placed on insulin infusions?on insulin infusions?

Extremely sick and physically Extremely sick and physically stressed patients.stressed patients.

No medical/surgical floor patients.No medical/surgical floor patients. Patients with glucoses above 200-Patients with glucoses above 200-

300 after failed attempts to lower 300 after failed attempts to lower glucose with sliding scale insulin glucose with sliding scale insulin therapy.therapy.

Page 4: Insulin Infusion Protocol in the ICU Changing Care…Changing Culture By: Holly Ann Roush, RN, BSN, Nurse Clinician level IV

What did management of the patient What did management of the patient entail?entail?

MD would order glucose levels to MD would order glucose levels to be check at a designated time be check at a designated time interval.interval.

Bedside nurse could only drawing Bedside nurse could only drawing and send a serum glucose. and send a serum glucose.

Results were available Results were available approximately 45-60minutes after approximately 45-60minutes after received by the lab. received by the lab.

Page 5: Insulin Infusion Protocol in the ICU Changing Care…Changing Culture By: Holly Ann Roush, RN, BSN, Nurse Clinician level IV

What nursing management was What nursing management was required?required?

Example: post operative open heart Example: post operative open heart surgery.surgery.

Serum would be sent for glucose Serum would be sent for glucose and other labs.and other labs.

Elevate serum glucose would be Elevate serum glucose would be reported to MD.reported to MD.

Intial treatment may be sliding scale Intial treatment may be sliding scale insulin by subcutaneous injection.insulin by subcutaneous injection.

Page 6: Insulin Infusion Protocol in the ICU Changing Care…Changing Culture By: Holly Ann Roush, RN, BSN, Nurse Clinician level IV

Nursing management Nursing management

Serum glucose rechecked. Serum glucose rechecked. • Elevated result reported to MD.Elevated result reported to MD.• Insulin infusion ordered and intiated.Insulin infusion ordered and intiated.

– with or without insulin bolus.with or without insulin bolus. Serum glucose levels then checked Serum glucose levels then checked

every hour.every hour. Adjustments made till glucose level Adjustments made till glucose level

lowered to an acceptable level.lowered to an acceptable level.

Page 7: Insulin Infusion Protocol in the ICU Changing Care…Changing Culture By: Holly Ann Roush, RN, BSN, Nurse Clinician level IV

Nursing Management Nursing Management continuedcontinued

Serum glucose and reporting to Serum glucose and reporting to MD usually continued hourly for MD usually continued hourly for duration of insulin infusion duration of insulin infusion therapy.therapy.

Page 8: Insulin Infusion Protocol in the ICU Changing Care…Changing Culture By: Holly Ann Roush, RN, BSN, Nurse Clinician level IV

Positive points of the past Positive points of the past management model.management model.

Work load decreased due to lower Work load decreased due to lower number of patients on insulin number of patients on insulin infusions.infusions.

Management is ordered patient Management is ordered patient specific.specific.

Page 9: Insulin Infusion Protocol in the ICU Changing Care…Changing Culture By: Holly Ann Roush, RN, BSN, Nurse Clinician level IV

Negative points of the Negative points of the past model.past model.

Few patients with adequate Few patients with adequate glucose control.glucose control.

Care is very time consuming in Care is very time consuming in correspondence with MD.correspondence with MD.

Blood loss/draw to do serum Blood loss/draw to do serum glucoses is high with sampling of glucoses is high with sampling of 3mls every hour.3mls every hour.

Page 10: Insulin Infusion Protocol in the ICU Changing Care…Changing Culture By: Holly Ann Roush, RN, BSN, Nurse Clinician level IV

More negative points!More negative points!

Excessive, but necessary time for lab to Excessive, but necessary time for lab to process and post glucose.process and post glucose.• patient is always receiving therapy for past patient is always receiving therapy for past

glucose level.glucose level. Unable to achieve optimal glucose Unable to achieve optimal glucose

control in a short amount of time.control in a short amount of time. It is difficult to treat multiple patients in It is difficult to treat multiple patients in

the ICU with insulin infusions.the ICU with insulin infusions.• Impossible for Floor RN Impossible for Floor RN

Page 11: Insulin Infusion Protocol in the ICU Changing Care…Changing Culture By: Holly Ann Roush, RN, BSN, Nurse Clinician level IV

Is there a need for Is there a need for change?change?

Maintaining blood glucose between 80-110mg/dl Maintaining blood glucose between 80-110mg/dl reduced ICU mortality by 42%. (reference #3)reduced ICU mortality by 42%. (reference #3)

Even moderately elevated glucose levels in the Even moderately elevated glucose levels in the critically ill patient can cause cytopathic hypoxia. critically ill patient can cause cytopathic hypoxia. (reference # 2)(reference # 2)

Accelerated toxicity of hyperglycemia and lack of Accelerated toxicity of hyperglycemia and lack of insulin effect is greatly associated to increase in insulin effect is greatly associated to increase in multiple system organ failure. (reference #2)multiple system organ failure. (reference #2)

Therepeutic control of glucose levels (80-120) Therepeutic control of glucose levels (80-120) reduces morbidity, mortality, and length of ICU reduces morbidity, mortality, and length of ICU stay. (#4)stay. (#4)

Page 12: Insulin Infusion Protocol in the ICU Changing Care…Changing Culture By: Holly Ann Roush, RN, BSN, Nurse Clinician level IV

Present Care of the Present Care of the Hyperglycemia.Hyperglycemia.

What patients are placed on insulin infusions?What patients are placed on insulin infusions? What does management of the patient entail?What does management of the patient entail? What nursing management is required?What nursing management is required? What are the positive points of treatment with What are the positive points of treatment with

an Insulin infusion protocol?an Insulin infusion protocol? What are the negative points of treatment with What are the negative points of treatment with

an Insulin infusion protocol?an Insulin infusion protocol?

Page 13: Insulin Infusion Protocol in the ICU Changing Care…Changing Culture By: Holly Ann Roush, RN, BSN, Nurse Clinician level IV

What patients are placed What patients are placed on insulin infusions?on insulin infusions?

Any adult inpatient can receive Any adult inpatient can receive therapeutic glucose control via an therapeutic glucose control via an insulin infusion.insulin infusion.• This includes medical and surgical This includes medical and surgical

floor patients, and patients on any floor patients, and patients on any admitting service.admitting service.

Page 14: Insulin Infusion Protocol in the ICU Changing Care…Changing Culture By: Holly Ann Roush, RN, BSN, Nurse Clinician level IV

What does management of the What does management of the patient on an insulin infusion entail?patient on an insulin infusion entail?

MD orders the Insulin Infusion Protocol MD orders the Insulin Infusion Protocol due to elevated glucose level or diabetic due to elevated glucose level or diabetic history.history.

Glucose control and insulin therapy Glucose control and insulin therapy collaboratively reviewed on daily collaboratively reviewed on daily bedside rounds.bedside rounds.

Nurse required to notify MD only if Nurse required to notify MD only if problems with glucose control due to problems with glucose control due to change in clinical picture.change in clinical picture.

Page 15: Insulin Infusion Protocol in the ICU Changing Care…Changing Culture By: Holly Ann Roush, RN, BSN, Nurse Clinician level IV

What nursing management is What nursing management is required?required?

Nursing clarifies/obtains order for insulin Nursing clarifies/obtains order for insulin infusion.infusion.

Nurse checks blood glucose using bedside Nurse checks blood glucose using bedside glucose meter.glucose meter.

Insulin infusion is administered via infusion Insulin infusion is administered via infusion pump after being double checked by pump after being double checked by another RN.another RN.

Bedside glucose checks are done hourly Bedside glucose checks are done hourly and infusion adjusted according to protocol.and infusion adjusted according to protocol.

Page 16: Insulin Infusion Protocol in the ICU Changing Care…Changing Culture By: Holly Ann Roush, RN, BSN, Nurse Clinician level IV

What are the positive points of treatment What are the positive points of treatment with an Insulin infusion protocol?with an Insulin infusion protocol?

Less time spent on care of single patient Less time spent on care of single patient with an insulin infusion. with an insulin infusion.

Can treat multiple patients effectively Can treat multiple patients effectively for hyperglycemia.for hyperglycemia.

Glucose control occurs more quickly.Glucose control occurs more quickly. Can safely treat patient to keep glucose Can safely treat patient to keep glucose

level 80-100mg/dl.level 80-100mg/dl. Infusion dose changes are done earlier Infusion dose changes are done earlier

in the point of care.in the point of care.

Page 17: Insulin Infusion Protocol in the ICU Changing Care…Changing Culture By: Holly Ann Roush, RN, BSN, Nurse Clinician level IV

More positive pointsMore positive points..

Cost savings to patient, hospital, Cost savings to patient, hospital, and insurance company.and insurance company.• Cheaper to do Glucometer checks Cheaper to do Glucometer checks

than serum labs.than serum labs.• Less days of stay in the ICULess days of stay in the ICU• Less days of stay in the hospitalLess days of stay in the hospital• Lower rates of nosocomial infections.Lower rates of nosocomial infections.• Less sequela of critical illness, injury, Less sequela of critical illness, injury,

or intervention.or intervention.

Page 18: Insulin Infusion Protocol in the ICU Changing Care…Changing Culture By: Holly Ann Roush, RN, BSN, Nurse Clinician level IV

More positive points!More positive points!

Allows nursing to be more Allows nursing to be more autonomous.autonomous.

More nursing hours spent in actual More nursing hours spent in actual patient care.patient care.

Glucose control can occur safely Glucose control can occur safely for a lower glucose level.for a lower glucose level.

Less blood loss for the patient.Less blood loss for the patient.

Page 19: Insulin Infusion Protocol in the ICU Changing Care…Changing Culture By: Holly Ann Roush, RN, BSN, Nurse Clinician level IV

Facilitators to acceptance Facilitators to acceptance of the Insulin Infusion of the Insulin Infusion Protocol.Protocol.

Move towards evidence based practice.Move towards evidence based practice. Piloted on a specific patient care Piloted on a specific patient care

population.population. Extensive educational inservicing on Extensive educational inservicing on

administration of insulin infusions as per administration of insulin infusions as per protocol.protocol.

Introduction and in-servicing of use of Introduction and in-servicing of use of bedside glucose meters in the bedside bedside glucose meters in the bedside setting.setting.

Page 20: Insulin Infusion Protocol in the ICU Changing Care…Changing Culture By: Holly Ann Roush, RN, BSN, Nurse Clinician level IV

Barriers to acceptance of Barriers to acceptance of the Insulin Infusion the Insulin Infusion ProtocolProtocol. .

Change is always resistedChange is always resisted Multiple modifications to the Multiple modifications to the

protocol protocol Increase workload on nursing staff Increase workload on nursing staff

with the added responsibilities.with the added responsibilities.

Page 21: Insulin Infusion Protocol in the ICU Changing Care…Changing Culture By: Holly Ann Roush, RN, BSN, Nurse Clinician level IV

ConclusionsConclusions

The term “hyperglycemic patient” needed The term “hyperglycemic patient” needed to be redefined in the inpatient clinical to be redefined in the inpatient clinical setting.setting.

Past treatment of hyperglycemic patients Past treatment of hyperglycemic patients with sliding scale insulin and patient with sliding scale insulin and patient specific ordered insulin infusions was specific ordered insulin infusions was inadequate.inadequate.

New methods of treating hyperglycemia New methods of treating hyperglycemia from hospital admission to discharge need from hospital admission to discharge need to be developed and explored.to be developed and explored.

Page 22: Insulin Infusion Protocol in the ICU Changing Care…Changing Culture By: Holly Ann Roush, RN, BSN, Nurse Clinician level IV

ReferencesReferences

Abourizk, Nicholas N., Vora, Chaula K., Verma, Parveen. Abourizk, Nicholas N., Vora, Chaula K., Verma, Parveen. Inpatient Inpatient diabetology: The new frontier. diabetology: The new frontier. Journal of General Internal Medicine. Journal of General Internal Medicine. May 2004, (466-471).May 2004, (466-471).

Berghe, Greet Van den. Berghe, Greet Van den. How does blood glucose control with insulin How does blood glucose control with insulin save lives in intensive care?. save lives in intensive care?. The Journal of Clinical Investigation; The Journal of Clinical Investigation; November 2004 114, 9 (1187-1195) .November 2004 114, 9 (1187-1195) .

Goldberg, Philip A., Siegel, Mark D., Sherwin, Robert S., Halickman, Goldberg, Philip A., Siegel, Mark D., Sherwin, Robert S., Halickman, Joshua I.; et al. Joshua I.; et al. Implementation of a safe and effective insulin Implementation of a safe and effective insulin infusion protocol in a medical intensive care unit.infusion protocol in a medical intensive care unit. Diabetes Care: Diabetes Care: Feb. 2004; 27, 2 (461-467).Feb. 2004; 27, 2 (461-467).

Vora, Amit C., Tipufaiz, Saleem M., Polomana, Rosemary C., Vora, Amit C., Tipufaiz, Saleem M., Polomana, Rosemary C., Eddinger, Victoria L., Hollenbeak, Christopher S., Girdharry, Dexter Eddinger, Victoria L., Hollenbeak, Christopher S., Girdharry, Dexter T., Joshi, Renu, Martin, Donal, Gabbay, Robert A. T., Joshi, Renu, Martin, Donal, Gabbay, Robert A. Improved Improved perioperative glycemic control by continuous insulin infusion under perioperative glycemic control by continuous insulin infusion under supervision of an endocrinologist does not increase costs in patients supervision of an endocrinologist does not increase costs in patients with diabetes. with diabetes. Endocrine Practice; March/April 2004.Endocrine Practice; March/April 2004.