I recently was working in the hospital talking with a patient about her diabetes management at home, when a nurse came in to check her blood glucose level (BG). It was an hour after she had eaten a meal, but the nurse appeared unconcerned. He then left the room and did not return. I spent a little more time with the patient and then headed to the nurses station to enter my dictation. The nurse was there, but did not intend to deliver the insulin yet. When I questioned about the way he would dose, given the tardiness of the BG check and the inability to assess the tray for food consumption (as it had been skirted away), he said he was planning to give insulin for the post-meal BG check as well as for the carbohydrates. I was a bit angered I have to say, so I checked every post when the Inpatient COI was buzzing with activity, much of it surrounding the challenge of timely insulin delivery in the hospital setting.
Patients often do not complete their entire meal tray because they feel poorly and meals at the hospital are totally different from home cooked meals (or fast food pick up), so pre-meal carbohydrate coverage is a challenge. With the focus on patient satisfaction surveys, perhaps to the detriment of better BG management, many hospitals have gone to meals on demand, rather than at fixed times, which makes clear timing of meal delivery difficult. Add to that the busy life of the nurse and occasionally the lack of diabetes training the nursing staff has had and insulin delivery can be many hours after a meal, creating a widely ranging BG response.
The standards of care for hospital-based insulin delivery is the use of basal bolus insulin with both correctional and carbohydrate coverage. After a careful review of literature, the ADA and the American Association of Clinical Endocrinologists released a consensus statement1 that says hyperglycemia is associated with poor outcomes. Basal, correctional and nutritional insulin are recommended components of inpatient subcutaneous insulin regimens. This is supported by a more recent publication from the ADA: the 2017 Standards of Diabetes Care-20172. Using only correctional insulin is no longer recommended in the hospital setting.
The goal is maximizing BG within target range, generally 140-180 mg/dl in the hospital setting. I’ve shared a number of helpful suggestions below. All suggestions are to alert the nursing staff to the tray delivery and a reminder to administer insulin in a timely manner.
- Different colored trays for patient with diabetes as a reminder of diabetes
- A light above the patient’s door activated when the tray is delivered
- A sticky note on the patients tray to remind them to call the nurse prior to starting their meal for their insulin dose
We have instituted the latter two in our hospital, along with ongoing diabetes educational sessions in person, at staff meetings and online. But insulin delivery continues to remain a challenge in the consistency of care we provide patients. Insulin should be delivered either before or after a meal, as close to meal delivery as possible, and recommendations within 30 minutes appear reasonable. The importance of the rationale for maintaining BG within goal for better patient outcomes should be a conversation with everyone responsible for the care of the inpatient with diabetes – providers, nurses, meal hostesses, and health care workers checking BG.
What has worked in your hospital setting that you can share?
- Moghissi E, Korytkowski M, DiNardo M et al. American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on inpatient glycemic control. Diabetes Care 2009;32(6):1119-1131.
- American Diabetes Association. Standards of Medical Care in Diabetes. Diabetes Care 2017;40(Suppl 1):S1-134.
About the Author:
Carla Cox is a registered dietitian and certified diabetes educator. She has been a certified diabetes educator for over 25 years, and served as an assistant adjunct professor for 14 years, teaching in areas of sports nutrition and exercise physiology. Currently she works in Missoula, Montana as a diabetes educator in both in- and outpatient settings.