1. Best Practices in Mealtime Insulin Administration By Diane Rolof, RN, BSN, CDE Diabetes Consultant, Regional Health

2. Integrated Healthcare System 5 Hospitals 2 Long-term Care 24 Clinics Employ 5,000+ Providers and Caregivers Recognized for Quality & Patient Experience ANCC Magnet Recognition® (Rapid City) Trauma Verified American College of Surgeons Trauma o Level II (Rapid City) and Trauma Level III (Spearfish) South Dakota Department of Health Trauma Verification – Trauma Receiving Facilities o Custer, Sturgis, Lead/Deadwood AHA Get With the Guidelines Stroke Award AHA Mission: Lifeline STEMI Award Healthstream: Insight Award “Overall Patient Experience” (Custer) Committed to the Future of Healthcare 32 Medical Specialties including: Orthopedics, Cardiac, Cancer Care 5 Schools of Nursing Graduate Nurse Residency program Medical Residency program 100+ active research studies Affiliations : Coverage Area 5 states | 250 mile radius 858,469 | South Dakota Population 373,618 | Service Area Population

3. Objectives 1.Discuss a process to identify enhancers and barriers to timely insulin delivery at mealtimes 2.Discuss a process that can be replicated that will improve the timeliness of insulin administration

4. Enhancers and Barriers – Human Resources Nursing Evaluation Includes: – Insulin Administration Insulin for carb intake and for glucose correction Variation in education re pre-meal or post-meal Variation in practice r/t education and “comfort level” of insulin timing Plan for knowing how much carbohydrate was consumed and plan for when pt. does not consume – Oversight of Patient Care Technicians Patient care technicians serve under nurses – Nurses need to evaluate patient care technicians practices r/t glucose testing and picking up meal trays of patients that are receiving insulin for carbohydrate intake

5. Enhancers and Barriers – Human Resources Patient Care Technicians – Pre-meal glucose testing Variation in practice r/t timing of glucose tests – Tray delivery and pick-up Plan for notifying nurse how much CHO was consumed Scope of Practice in our state does not allow PCT’S to count carbohydrates unless that have had a competency test on carb counting Dietary Staff – Tray delivery Education regarding need for glucose check prior to tray delivery – Tray pick-up Plan for notifying nurse how much CHO was consumed

6. Other Enhancers and Barriers Supplies Evaluation – available when needed – Insulin pens and needles availability – Glucose testing supplies availability Electronic Medical Record Evaluation – Insulin orders define administration time Our orders state to give insulin for carbohydrate intake when the meal is served or within 20 minutes of the first bite of the meal – Process from glucose test until results in EMR Involve laboratory personnel to evaluate any issues with the glucose meters or delays in transmission of the glucose readings to the EMR We require nurses to use the glucose test in the EMR rather than a hand written note with result – too many errors with transcription can happen – Process from medications scan to EMR Our scanning process when using insulin pens involves 3 scans – patient name band – insulin pen device (to verify the pen is only used on one patients – insulin medication to verify right kind of insulin is being given

7. New Process to facilitate insulin is given within 45 minutes of the glucose test Glucose testing begins when meal trays arrive on the nursing unit – Previously testing began when the staff anticipated the trays would arrive Meter is docked after each test – Previously the meter was docked after all the glucoses on the unit had been checked. Staff thought this was more efficient, but time studies demonstrated that this perception was not valid Log kept to note if the glucose test has been completed – Informs dietary staff the glucose test is done and the meal tray can be delivered Insulin is dosed off the glucose in the EMR – To prevent errors r/t transcription Insulin is given as the meal is served or within 20 minutes of first bite of the meal – per standardized provider orders Systematic roll-out of process to all patient care areas

8. Evaluation Daily audits in each patient care area of the time from glucose test until insulin was administered – Audits were done by staff in the patient care unit – This helped with accountability and also helped achieve buy-in from staff Celebrated the successes – Kudos to individual staff and departments as we saw improvements Crucial conversations prn – Nursing units manager were involved in audits and had conversations with individual staff when improvement was needed Posting of results on the patient care areas – Helped keep the process fresh in everyone’s mind

9. Our Results at End of Formal Audits % of Aspart insulin injections given within 45 minutes of the glucose test Baseline data was collected in 4 th Quarter 2015 New process began on one patient care unit in February, 2015 Rollout to all patient care areas was completed in July, 2015 Formal mandatory audits ended December, 2015

10. Random Audit 6 months Later % of Aspart insulin injections given within 45 minutes of the glucose test The % of timely insulin injections was dropping. Action was needed to change the direction we were heading. 4 th Qtr 2014Dec 2015June 2016 35%79%69%

11. Lesson Learned Process ownership is vital to success Ongoing oversight needed for success Onboarding insulin education plan for – New nurses – Traveling nurses – Patient Care Techs Education Plan needed for Student Nurses

12. Revised Plan Nursing Management would assume role of process owner of insulin administration process Nursing Management would audits New nurse orientation was revised to include an e-learning module that included the process for achieving timely insulin injections for our patients Traveling nurses will have insulin timing education included in their orientation We will meet with faculty from all of our nursing programs so that the process will be included in their education modules

13. Questions