LawMed Nurse Consulting: Lunch and Learn Session #2: Avoiding Severe Hypoglycemia
Twitter Space - July 13, 2023 @ 12pm MST
Let me begin by stating that, although some of this may seem elementary, medical providers, and attorneys concerned with medical malpractice matters, (as well as diabetic patients), should understand how common these knowledge deficits are, even in the ICU. This may be due to the large number of new graduate nurses forced into ER and critical care units these days. You see, there is poor staffing, which can most certainly have been made much worse by vaccine mandates, as well as the COVID culture invading hospitals. The more experienced nurses with heavy critical thinking skills may be missing in action from these critical care units, which I have written about in a previous article on Substack, found at the following link for later reading.
NOTE: My first “lunch and learn” session on twitter was very well-attended by clinicians, and was about the proper use of Naloxone. I regret not posting an accompanying article on Substack about it, as there are many pitfalls in that arena.
***If you prefer to LISTEN to the Twitter space, here is the link!
https://twitter.com/LawMedLegalRN/status/1679570190047260672?s=20
For this important second educational session, I began with a very basic review of the diabetes types for those in the audience who are not in the medical profession,… especially any attorneys who may be interested. The brain needs sugar to operate. Severe hypoglycemia can cause death, and the instances of seriously low glucose levels in the 30’s and 40s, (normal fasting level 80), are prevalent, as I can attest from my time as a clinical educator in both acute care and long-term care settings. The amount of rescue with Dextrose boluses and the fact that patients need to be brough back from the ledge so often, is something that can truly be prevented. My educational program rollout in 2016, Los Angeles, resulted in a 63% decrease in these instances, as tracked by pharmacy and the quality assurance statistics.
“In a person with type 1 diabetes: the pancreas constantly tries to produce beta cells in order to make insulin, but the immune system continues to attack and destroy most or all of those beta cells. For those with type 1 diabetes, the evolution of the disease and the attack on the beta cells occur very quickly, which means people get sick very quickly. Immediately upon diagnosis, patients should begin taking pharmaceutical insulin via pump, pen, or syringe” (https://diabetesstrong.com/insulin-types/).
“In a person with type 2 diabetes: the body is either struggling to produce a normal amount of insulin (for reasons still unknown), or the body is struggling with severe insulin resistance which makes it difficult to manage healthy blood sugar levels with the available amount of insulin. For those with type 2, the struggle to properly produce or make use of their own insulin is usually a slower process, sometimes taking years before you show strong enough symptoms to warrant an HbA1c test, a diagnosis, and eventual treatment” (https://diabetesstrong.com/insulin-types/).
Root Cause Analysis: Bautista, S., 2016 (Clinical Educator in Los Angeles).
Upon conducting an educational needs assessment of my staff at a community hospital in Los Angeles, I discovered overwhelm, of course, however, I also discovered the following:
1. Patients were on the same high sliding scale coverage as at home, even though they were ill, not eating as much, NPO for certain diagnostic tests at times, and were not as eager to eat hospital food as they were their non-compliant diets at home.
2. Patients were on Metformin, along with several insulins.
3. Patients were being given insulin doses BEFORE there was a plan to feed their patients who could not feed themselves. The trays were delivered to the floor, but were either not picked up, OR were placed at patient bedsides that were total feeders. In essence, PO intake was not being addressed upon administration of insulin.
4. Nurses were very duty oriented, (in other words), they had their list of tasks to complete on a list, however, very little critical thinking was being utilized when they were drawing up their insulin doses.
5. Basal and Bolus insulins were being given with very little consideration of peak times, especially with patients on Metformin as well. The nurses needed education about holding insulins, and not only calling physicians to inform them, but also having the confidence to ask a physician if a current regimen could be modified.
6. Use of pens and needles were varied in accuracy when drawing up insulin and injecting. Nursing educators had not been available for new nurses transitioning to practice. There was a serious need for one of one and group education of the staff.
Although my assessment was initially held on a medsurg unit, I extended my educational needs assessment to the ICU, where patients were eating even less, had tube feedings turned off often for turning and hygiene care, and were often sent off unit without any glucose for diagnostic testing. Sometimes IV fluids did not provide any back up, and insulins were again, inappropriate for the situation. All of this is not a nursing error, however, the lack of time for contacting physicians, as well as the lack of receptivity in hospitalists, was problematic in solving this issue.
Barriers to Patient Safety: Bautista, S., 2016 (Clinical Educator, Los Angeles).
1. Knowledge deficit on part of new nurses.
2. Time constraints due to poor nurse:patient ratios.
3. Lack of confidence in new or young nurses to contact physicians.
4. Lack of hospitalist receptivity of nursing communication or suggestions.
5. Lack of understanding of the PO agents and insulin types, as well as peak times.
6. Lack of acknowledgement about patients with poor PO nutritional intake and feeding needs.
7. Reactive vs. preventive medicine.
8. Dextrose 50% being given and then no follow-up modifications or monitoring being done.
Insulin Types
“Let’s look at each type of insulin and all the pertinent information that goes along with it, including onset (how fast it starts to work in the body), peak times (when the insulin works the strongest), and duration (how long it is active in the body), and more. Finding the ideal combination and regimen for a patient can take a great deal of time” (https://diabetesstrong.com/insulin-types/).
At this point, as the clinical educator in this acute care hospital in Los Angeles, I realized the nurses needed a cheat sheet for insulins. COWs are computers on wheels that nurses utilize when giving medications so that they can document. For the purposes of this article, I will not print out the exhaustive list of names for each of the insulins types, however, I did do this for the nurses on the units, as a handy resource. They could easily glance at the laminated bullet points and see when each insulin peaked. This increased the safety of administration, and lowered the overwhelm.
Rapid-acting insulin
Short-acting insulin
Intermediate-acting insulin
Long-acting basal insulin
Along with knowing which insulins do what, and WHEN, there must also be accurate methods of administration. Clinical educators MUST do one on one training with nurses during which time their skills are validated, so that doses delivered are as intended.
“The three greatest benefits of delivering insulin via pump or pod, compared to a syringe or pen, are:
1. The ability to deliver extremely precise dosing options, down to 0.025 units.
2. The ability to suspend or quickly reduce insulin delivery to compensate for variables like exercise, or for a picky toddler who decided halfway through dinner to stop eating.
3. The freedom to eat something, take insulin, and then eat more just a bit later all with the push of a button rather than another injection.
While an insulin pump is the most advanced insulin delivery option available today, it isn’t necessarily the best fit for everyone.
Insulin pumps and pods do come with a few flaws, including:
1. The supplies for pumps and pods are far more expensive than syringes and pens.
2. A mechanical or physical error that results in severe high blood sugars and requires a new infusion site set-up.
3. Every 3 to 4 days, the user must take time to remove the current infusion site and set-up a new one” (https://diabetesstrong.com/insulin-types/).
I hope that you enjoyed this presentation, whether you read it or listened to the the twitter space recording. Please share it with clinicians, medmal attorneys, and DM patients.