1. 1 Module 6 Review of Policies and Order Sets Diabetes Special Interest Group Georgia Hospital Association

2. 2 In this module you will review policies and procedures related to diabetes Learning Modules Module no.Topic 1Hyperglycemia and hospital outcomes 2Current status of diabetes care at MCH 3Initial recognition, triaging, and management 4Principles of pharmacologic management: Insulin 1 5Principles of pharmacologic management: Insulin 2 6Review of policies and procedures 7Preparing patients for discharge

3. 3 Objectives Discuss the comfort level of caregivers managing blood glucose during hospitalization Review policies and pre-printed glucose control order sets Review hypoglycemia policies and order sets

4. 4 Resource For slides 5, 6, and 7 reference: Endocrine practice [1530-891x] Cook yr:2010 vol:16 iss:2 pg:219-30 Cook CB, Elias B, Kongable GL, Potter DJ, Shepherd KM, McMahon D. Diabetes and hyperglycemia quality improvement efforts in hospitals in the United States: current status, practice variation, and barriers to implementation. Endocr Pract. 2010 Mar-Apr; 16(2):219-30. PubMed PMID: 20061279. ID:20061279

5. 5 Comfort with Treatment Mayo Clinic Arizona Treating hyperglycemia Treating hypoglycemia Using subcutaneous insulin Using insulin drips Responses in each category, % 29 69 2 27 63 10 33 65 2 12 38 48 2

6. 6 Resident Familiarity with Policies Mayo Clinic Arizona Insulin pump policy 2 58 40 Hypoglycemia policy 10 49 41

7. 7 Resident Familiarity with Preprinted Orders Mayo Clinic Arizona Subcutaneous insulin orders 65 25 10 Intravenous insulin orders 16 54 30 Insulin pump orders 2 54 44

8. 8 Therapy Decision Tree Helps identify patients at risk for hyperglycemia Identifies when insulin therapy would appropriately be initiated Identifies which therapy method would be most effective

9. 9 IV Insulin Infusion Order Set Is nurse driven Does not require the nurse to do any math Identifies when the physician should be notified Has hypoglycemia management plan Considers the patient’s individual insulin sensitivity

10. 10 Subcutaneous Basal Bolus Adult Order Set Addresses –Blood glucose testing plan –Meal plan –Hypoglycemia management plan –Meal bolus –Correction bolus –Basal insulin requirement

11. 11 Subcutaneous Regular and NPH Insulin Order Set for Gestational Diabetes Addresses –Blood glucose testing plan –Meal plan –Correction insulin orders –Scheduled insulin orders –Hypoglycemia management plan

12. 12 Continuous Subcutaneous Insulin Infusion (Insulin Pump) Policies The policy was developed to enhance safety while preserving the patient’s ability to self-manage Components include: Set of contraindications Patient consent form Standing orders Flow sheet Metrics

13. 13 Insulin Pump Use in the Hospital: Contraindications Altered state of consciousness Depression and/or suicidal ideations Critically ill patient requiring intensive care Patient refuses or unable to participate in own care

14. 14 Insulin Pump Contraindications Continued Family member, friend, or significant other refuses or unable to participate in care Radiology procedure Other identified circumstances

15. 15 Peri-operative Order Set The peri-operative order set provides for glucose control during short stay surgery.

16. 16 Hypoglycemia Treatment Plan Stratified according to patient mental status and glucose level Addresses route of treatment (oral, IM or IV) Identifies when to notify physician Identifies when to test blood glucose Identifies when to verify with venous lab value

17. 17 Discharge Plan Identifies who is responsible for instructing the patient on diabetes self-care Identifies educational objectives to be met prior to discharge Provides standardized documentation form that outlines the educational objectives for the teaching process. Form should also provide space for documenting educational outcomes

18. 18 In Summary Diabetes care is complicated and requires a multidisciplinary team. Patient safety and healthcare outcomes can be improved by the use of order sets based on hospital policies