Building and Implementing the Subcutaneous Insulin Order Set/Protocol

Greg Maynard, Dave Wesorick, Cheryl O’Malley, Maryann Emanuel, Robert Rushakoff

The Basics

This link will lead you to a bare bones example of a standardized subcutaneous insulin order form. We want you to appreciate that this basic order set can probably be markedly improved, but that it also has good features/core components that you will want to include as you improve on this basic model. Even this basic order set can provide very powerful results if you use the reliability tips featured in the previous section. In the vernacular of the prior chapter, we will be working on elevating this basic order set from a level 2 or level 3 on the reliability hierarchy to a level 4.
Note the recommended features/components of these orders:

1. Checkbox simplicity on when to order appropriate glucose monitoring.
2. Use of encouraged insulin terminology: basal, prandial (or nutritional), and correctional. Language is a powerful thing, and just getting staff to use these terms goes a long way toward the more physiologic prescribing of insulin.
3. Statement/reminder of a glycemic goal.
4. Elimination of unapproved abbreviations (like U for units).
5. Stating both generic and brand names of insulins.
6. Important timing cues for administration of insulin.
7. Several correction-dose scales suitable for different insulin sensitivities. One size does NOT fit all.
8. Incorporation of a simple hypoglycemia protocol into the order set
9. Supplementary insulin dosing guidelines available at the point of care (in this case, on the back of the order set).
10. Default selection when possible for all choices offered in order to minimize omissions from the orders.

Where appropriate, offer the ability to specify individualized goals (eg, BG target range) or doses (eg, correction-dose insulin scale).
This basic order set does incorporate many of the high-reliability design features mentioned in the previous section. One high-reliability design concept bears repeating to ensure wide use of your order set.
Strip out all other subcutaneous insulin order sets from your institution. A review of post-op, transfer, and admission order sets that all services use will probably reveal a dozen or more embedded sliding-scale insulin order sets that need to be eliminated, as you make your order set the only easy way to order insulin. Of course, doing this without talking to the services using these lesser versions could result in a political black eye, so be sure your team makes the rounds to do prior notification. If you have problems with this step, it is probably an indicator of inadequate institutional support. Make sure your team is empowered to make these changes and gets all the changes approved by the appropriate committees.
So, once we have education in place and this basic order set, that should pretty much do it, right? An emphatic “NO!” is the answer to that query!

You should certainly see some meaningful results with these interventions, but dealing with hyper­glycemia and diabetes in the hospital is very complicated, and physicians, nurses, and others will need all the help they can get. The next section gives some examples of how to improve per­form­ance to a much greater degree than you could expect with this order set and education alone. This in­volves creating a detailed algorithm and integrating the algorithm into your order set as much as possible.

We will now proceed on a step-by-step process for your team to begin building your own institutional approach. This approach should become incorporated into your policies, protocols, and algorithms. At the end of this section, you will then incorporate many of your decisions and choices into the blank template algorithm, as an example of how you can concisely convey a wealth of information to your staff. View the blank template algorithm

Choosing a Glycemic Target for Non–Critical Care Areas

It is important to adopt a glycemic target that is institution-wide, for critical care areas and non–critical care areas alike. The means you choose to identify and communicate your glycemic target need not be identical to the ADA/AACE glycemic targets, but should be similar to them.
Examples of glycemic targets for non–critical care areas:

• Preprandial target 90–130 mg/dL; random glucose < 180 mg/dL (ADA/AACE consensus target)
• 80–150 mg/dL
• Preprandial target 90–130 mg/dL for most patients, 90–150 mg/dL if hypoglycemia risk factors

Your team should pick the glycemic target it can most successfully implement, disseminate, and get buy-in for.

Methods to make your glycemic target effective

• Place your glycemic target on all policies, order sets, and algorithms.
  
• Make your glycemic target “actionable.”

What happens if your institution’s glycemic targets are not being met? Glucose values con­sis­tent­ly out of your target range without attempts by physicians to tighten control warrants in­sti­tu­tional ac­tion. Consider creating parameters for calling the physician if glycemic targets aren’t met as a stand­ing order, or integrate a few limited choices for glycemic targets into your insulin order sets, which trigger calls from nursing should glucose values fall persistently outside this range. Some institutions print out all glucose values for their monitored patients on each ward on a day-to-day basis, along with their glucose control regimen. Pharmacists or nurses get involved in asking for physician action and presenting recommended choices (such as adding scheduled basal insulin). Others refer similar information to a “hyperglycemia hit squad.” Certain electronic medical rec­ords may have the capa­bil­ity of prompting physician action when glucose values are out of the target range. The what to do is common across all institutions: push for order changes when glycemic targets aren’t met. The spe­cifics of the glycemic target and the who and the how the spur to action occurs is institution specific.

Policy on Obtaining Inpatient HbA1c Levels

Obtaining a HbA1c can be quite helpful in gauging how well the patient’s outpatient regimen is maintaining glycemic control, distinguishing stress hyperglycemia from established diabetes, and guiding the inpatient approach to glycemic control. ADA guidelines recommend obtaining HbA1c levels of inpatients if not already available from the month prior to admission. (If lab delays are problematic, POC A1C testing is available from some vendors.)

Methods to obtain broader use of HbA1c

• Incorporate HbA1c lab orders into your insulin order set and prompts for obtaining HbA1c into your algorithms and policies.
  
• Place HbA1c next to point-of-care (POC) glucose monitoring orders.
  
• Monitor and provide feedback to physicians via nurses or other personnel.

Consider including a component that prompts the prescriber to accurately specify the hyperglycemia-related diagnosis. The SQ order set may include the ability for the prescriber to specify the hyperglycemia-related diagnosis. This will allow improved accuracy of documentation.

Ordering Diabetes Education and Appropriate Consultation

Diabetes education should be offered to all hyperglycemic patients, complete with written materials, a listing of community resources, and survival skills (see the Comprehensive Educational Programs Section). Consultation with physicians in internal medicine or endocrinology for difficult-to-control cases, or for cases in which the primary physician of record is not familiar with (or not adherent to) principles of inpatient glycemic management should be very easy to obtain, or perhaps mandated, depending on your institution-specific environment.

Methods for effective implementation

• Place prompts for diabetes education in algorithms, policies, and order sets.
  
• Make diabetes education a standing order for all patients with hyperglycemia. Frontline nursing will likely have much of the responsibility for educating patients about diabetes, but diabetic educators, pharmacists, and others should play a role in educating selected patients.
  
• To obtain consultations, use triggers such as not meeting the glycemic target or monitor for insulin regimens that do not include scheduled basal insulin as a trigger for consultation or referral to a “hyperglycemia hit squad.” Put contact information for diabetes management consultation/assistance into your order sets and other easily accessed areas.

Monitoring Glucose Level: Guidelines for Frequency of Monitoring

Offering guidance for frequency of monitoring should be integrated into your algorithms, policies, protocols, and order sets. With insulin infusion, the default frequency is monitoring every hour until glucose levels have stabilized on a constant drip rate, at which time the frequency of monitoring can sometimes be reduced to every 2 or 3 hours.

For non–critical care areas, the minimum frequency for patients on subcutaneous insulin regimens is q ac and hs for the eating patient and every 6 hours for the patient with no nutrition or with a constant source of nutrition (like continuous enteral feedings, for example). The ideal monitoring frequency may hinge on the insulin regimen chosen for a given situation. For example, a patient who is NPO might be on glargine as a basal insulin and on a rapid-acting analogue as a correction insulin. The frequency of monitoring and administration of the correction insulin would logically be every 4 hours. However, if the same patient has regular insulin as the correction insulin, it would probably be more logical to monitor and administer the correction dose every 6 hours instead of every 4 hours in order to accommodate the longer action of regular insulin.

There will be more examples of this in the section on preferred insulin regimen choices for patients in different nutritional categories.

Methods to estimate the dose of insulin
Caregivers need guidance on how much subcutaneous insulin they should give a patient. The fear of hypoglycemia usually results in substantial underdosing of insulin. Your team should provide guidance for how much insulin to start a patient on when it is unclear from past experience how much insulin the patient needs. Waiting a few days to see how much insulin is needed using sliding-scale-only regimens is a bad practice that should be discouraged for patients whose glucose values are substantially above the glycemic target.
The following three methods are recommended for arriving at a good starting dose for subcutaneous insulin therapy:

1. Calculating the subcutaneous insulin dose on the basis of the amount of insulin required in insulin infusion to maintain good glycemic control (details on ways to do that follow).
2. Adding up the total dose of insulin used in the patient’s home regimen, then adjusting the dose based on the patient’s nutritional intake, glycemic control on the home regimen, and other factors that might influence the insulin requirement (such as administration of high-dose glucocorticoids, severe acute illness, which could increase the insulin requirement, or acute renal failure, which could reduce the insulin requirement).
3. Calculating the dose based on weight and body habitus. The guidance you give should usually be to suggest a total daily dose (TDD) of insulin that a patient needs in a day. The TDD is the amount of insulin a patient requires to stay in good glycemic control, assuming he or she is receiving 100% of the nutritional requirement. The aggressiveness of the TDD estimate you offer depends on how sophisticated your target audience is. If you are providing guidance to a wide range of providers for a wide range of patient situations, it is probably wise to be less aggressive in your TDD calculations. The key is to give the provider a comfortable starting point for starting scheduled insulin that will not produce hypoglycemia. An experienced physician or endocrinologist can adjust these estimates upward, but a less experienced physician may not yet have the expertise to know when it is safe to do so. An important caveat: this calculation of the TDD presumes that oral hypoglycemic agents have been discontinued for the hospital stay. We reinforce that none of these dosing estimates will be perfect for all settings and that they are to be considered “ballpark” estimates for where to start. Recommendations based on weight, body, habitus, and other factors are:
1. If patient is very lean, on hemodialysis, very sensitive to insulin, or has hypoglycemia risk factors, the estimated TDD is 0.3 units/kg/day.

• For a standard patient with normal body habitus, the estimated TDD is 0.4 units/kg/day.
  
• For an overweight patient, the estimated TDD is 0.5 units/kg/day.
  
• For a patient who is obese or on high-dose steroids or known to have a high degree of insulin resistance, the estimated TDD is 0.6 units/kg/day or more.
  
• Adjust the TDD estimate up or down based on a patient’s glycemic control on prior regimens.

Note that these guidelines frequently underestimate the actual insulin dose required and they err on the side of providing conservative starting points to a variety of providers of variable sophistication. They could be more aggressive if aimed at endocrinologists, who would be more mindful of when to vary these suggestions downward based on individual patient characteristics.

Distribution of Scheduled Basal Versus Nutritional Insulin

50/50 Rule and Guidance for Adjusting Nutritional Insulin
When Nutrition < 100% or Interrupted

For 40%–50% of patients, the TDD should generally be basal insulin. We generally recommend promoting that 50% of the TDD be given as basal insulin, with the other 50% administered on a scheduled basis to cover glycemic excursions from nutritional intake. The 50/50 rule has the advantage of being easy to remember and to calculate. However, in some settings, a ratio of 40/60 (or even lower) is preferred (such as a patient on continuous tube feeding). The 50/50 rule generally works well, however, and should be widely promoted.

The TDD assumes patients are taking in their full nutritional requirement. For the 50% of the TDD that is nutritional insulin, you must include guidance advising to reduce the nutritional insulin dose proportionate to nutritional intake.

Methods to incorporate TDD and proper distribution of scheduled basal/nutritional insulin

• Build algorithm with specific preferred insulin regimens for each special situation as outlined below.
  
• If you have CPOE, autocalculate a TDD and distribution of insulin for the provider (see UCSD example).
  
• Pharmacy or nursing (or a hyperglycemia hit squad) can review regimens in their clinical areas and give suggestions to the ordering physician.
  
• Include algorithm and guidance at point of care as much as possible, including on the back of paper order sets, on posters in the wards, or as an integral part of the order set.
  
• Specific instructions for what to do when nutritional intake should be incorporated into your MAR and policies. (Example: “Give full dose of glargine if nutrition is interrupted; do not administer nutritional insulin; give correction dose insulin.”)

Timing of Insulin Administration, Glucose Monitoring, and Nutritional Delivery

Guidance for the timing of insulin administration should always an integral part of the order set. Unfortunately, having this guidance on the order set does not automatically translate into being carried out in the real world. Unless you have tackled this issue already, you should expect to find wide variability in the linkage between glucose monitoring, nutritional delivery, and insulin administration. A process-mapping session utilizing frontline workers is recommended in order to investigate your current practices and to plan interventions to improve them. Performance on an auditing basis should also be tracked and trended
(see the Track Performance>Utilization Metrics section).

CHOOSING INSULIN REGIMENS FOR PATIENTS WITH DIFFERENT FORMS OF NUTRITIONAL INTAKE

Each form of nutritional intake has many options for insulin regimens. Your team can gain some traction in encouraging physiologic insulin regimens by choosing just one of the acceptable regimens for each situation. This is essentially a step toward standardization of the care of the hyperglycemic inpatient. Choosing one preferred method for each nutritional situation and other special situations is advantageous because:

1. You can communicate preferred regimens more simply and succinctly to all staff.
2. You eliminate all inappropriate choices for insulin regimens for that situation, as well as some other less preferred, but acceptable choices.
3. You can encourage regimens that are most favored costwise (by choosing the rapid-acting analogue, your medical center can get the best price, for example).
4. Staff members can become very familiar with a few regimens, instead of being confused by a multitude of them. They can identify variations from your preferred choices and target these patients for extra scrutiny and actions should they fail to meet glycemic targets.
5. It lends itself to building protocols more than the inherent variability in usual practice.

The same type of insulin should be used for nutritional coverage and for correction coverage, and your order sets should reinforce this.

For most of the situations that follow, we’ll be referring to choosing the preferred subcutaneous insulin regimen. Insulin infusion is generally preferred for patients in critical care, undergoing major surgery, on initiation of TPN, and in several other situations, so special mention of this preference should accompany any recommendation for a specific subcutaneous insulin regimen in these settings.

Approach to Patients Eating Regular Meals
Approach to Patients Who Are Not Eating or Otherwise Taking Regular Nutrition
Approach to Patients on Continuous Enteral Tube Feeds
Approach to Patients on Bolus Tube Feeds
Approach to Patients on TPN
High-Dose Glucocorticoids
The Grazing Patient

Discharge Planning

Your institution should have policies and procedures outlining all the steps needed to complete the all-important transition out of the hospital. At a minimum, this planning should include adequate education (including a learner assessment), appropriate follow-up, referral to community resources, and a discharge glycemic control regimen that is tailored to the educational, financial, and motivational profile of a patient. The more “protocolized” your inpatient insulin regimens are, the more likely is the patient to be on a much different glycemic control regimen than the one on admission; therefore, it is even more important to plan this transition carefully and reliably. Communicating hyperglycemia and related problems is important for good care, perhaps even more so for patients who had hyperglycemia while hospitalized without a prior diagnosis of diabetes.

Methods to enhance the reliability of all these steps and more are covered in Transitions and Perioperative Settings.

Once you’ve settled on your own institution’s approach to all the issues in this section, it is time to place them into an algorithm. Print the blank-template algorithms and the example algorithms from UCSD. Then insert your own strategies into the blank-algorithm template and modify as desired, and you will have a powerful tool to augment your standardized order set. Incorporating your algorithm into your order sets and other materials at the point of care will ensure that your preferred strategies are used as the most common default strategies.