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Stacy Starbird-Richmond RN, CDE Mane Medical Center Portland, Maine

Stacy Starbird-Richmond RN, CDE Mane Medical Center Portland, Maine. Stacy received her bachelor’s degree in Nursing from the University of Maine at Orono, and is a Certified Diabetes Educator in Maine.

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Stacy Starbird-Richmond RN, CDE Mane Medical Center Portland, Maine

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  1. Stacy Starbird-RichmondRN, CDEMane Medical CenterPortland, Maine Stacy received her bachelor’s degree in Nursing from the University of Maine at Orono, and is a Certified Diabetes Educator in Maine. Stacy presently works at Maine Medical Center as a nurse and diabetes educator, and has been instrumental in training nurses and other clinicians on the newly implemented basal/bolus/correctional insulin protocols. Her passion for helping to improve the lives of persons’ with diabetes is evident in her work.

  2. Education with Energy! Moving Mountains, Creating Bridges Inpatient Nursing Education for New Insulin Protocols Stacey Starbird-Richmond, RN, CDE Diabetes Educator Glycemic Control Project Maine Medical Center starbs@mmc.org

  3. Clinical Services Strategic Planning (CSSP): 10/1/07-present • Administration • Physician Champions • Project Manager: Charlotte Bailey-McPherson • 20 hours • Physician: John Devlin, MD Endocrinologist • 4 hours • Nursing Education: Stacey Starbird-Richmond, Diabetes Educator • 20 hours (4/08) • Information Services • Nursing Research • Representatives from Nursing, Nutrition Services, Medical Staff, Pharmacy, Information Services

  4. PurposeYear 1 “Getting Insulin Right” NURSING EDUCATION • Write IV and SQ insulin order sets • Transition protocol • Hypoglycemia protocol • Nutrition Services (CHO awareness) • Focus Groups • Education -- RN, MD, Nutrition, etc. • Trial on R3 • Go Livehouse wide • Coordinate with other MaineHealth hospitals • JCAHO voluntary certification for Inpatient Diabetes Care

  5. HURDLES • New Employee • 506 bed hospital • New to in-patient hyperglycemia • Not consulting on units, no bedside patient ed • Maine Center Diabetes • Out-patient 11 years • R7 Cardiology 8 years • Structure MMC • Leadership, Management, Nursing, Hospitalists, Roles, Pharmacy, SCM, computer systems • Connections & Resources • Lost • Renew & establish • New Culture: Basal, Prandial, Correctional Insulin

  6. Review of Literature. Inpatient Project Where at ? Integration into team. What currently exists? Old policies/protocols Non-existent ones Lack of education Lack of guidelines Where is Nursing at? Who are my Resources? HURDLES Many ideas

  7. Where are nurses at? What do they need? Nursing Research Kristina Hyrkas 8 units 18 groups Four Questions Your thoughts and feelings about glycemic control? What protocols are you using on your unit? Perceive as benefits of implementation of a glycemic protocol? Perceive as challenges? Nursing Focus Groups

  8. Thoughts & Feelings • It’s important • As a Magnet, MMC should do better. • Opportunity for education • Based on evidence • Too many protocols • Not have good one for people that are eating. • I’m often telling patients we’re really screwing up their BSs • Achievable for RN to do • We do a poor job • We’re making excuses instead of fixing • Only treat BG > 150 • All we have is a sliding scale, not adjusting for carbs, just doing what the number says • Comprehensive program would be helpful

  9. Perceive as benefits? • Consistency • Sets expectations • Accountability • Better control • Wound healing, ↓ infections, outcomes, ↓ LOS

  10. Perceive as challenges? • Nurses • Education, staffing, support • Level of education among peers is different • Lucky we have CNAs to do BSs • We rise to challenge, but tough • many drips, making assignments for safety, overwhelming

  11. Perceive as challenges? Nursing Focus Group? Needs Assessment? • Nurses • Physicians • Education • Buy-in • Surgeons like to cut, sew. Don’t want to deal with anything else • Endo consults • BG control, pebble in their shoe, an irritant, they just want to get rid of it a opposed to really addressing it • Scary when you have a resident that orders Lantus as a sliding scale because they don’t know Lantus is long-acting.

  12. HURDLES- Establish Resources Know your resources • Director • MMC Structure • Staff Development • Clinical Specialists • Clinical Nurse Leaders • Assigned to units • Unit Based Educators (UBEs) • Other Unit Educational Liasions • Directors & Mangers • How do systems & departments work? Be assertive Meetings? Communication Dept. heads Connections Start climbing Introduce yourself

  13. Buy-In • If you call…will they come? • Administration Support? • Nursing Administration, Unit Directors • Is your protocol education mandatory? • Highly recommended • Identified Super-users or Champions • Super-user classes? • Diabetes or Glucose Resource Nurses • Unit based • How to deliver? “Time & $$$” “one more thing”

  14. Buy-in • Advanced vs Basic Classes • Need consistency • Need to know basics: providing basal, prandial, correctional insulin vs. sliding scale insulin • All educational modalities • Nurse focus groups • Meet unit and individual learning needs • Upfront & Blitz education

  15. Education Framework What access do you have to units & the staff? Make connections! Show your face! Shadow! • Summer/Fall 08 • Nursing unit & medical staff meetings • All hours • Tracking spreadsheet • Beginning, middle, end of project… • Nursing Leadership, Management, UBE, Practice & Nursing Council monthly meetings. • Basic concepts: Basal, Prandial, Correctional • New infusion protocols • Education • Hospital Nursing & Medical newspapers

  16. Yearly competencies Units vary Requirements & timing Poster Boards e-Learns Computerized PowerPoint lessons Q & A, traceable Express In-services Small poster size/legal Staff sign back Monthly Unit In-services Unit bulletin boards Unit Newsletters Email Intranet, Net News Bathroom Bomb shells Staff meetings Unit leadership teams Contact hours Utilize existing bridges!! Deployment of Education & Information ? Ask units… How they effectively deliver information to staff?

  17. Basal/ NutritionalInsulin Therapy Presented at staff meetings Breakfast Lunch Dinner aspart aspart aspart Plasma Insulin glargine 4:00 8:00 12:00 16:00 20:00 24:00 4:00 Time

  18. Nursing Newsletter-Getting Insulin Right The Inpatient Glycemic Control Project “Getting Insulin Right” is a three year Clinical Services Strategic Planning (CSSP) project that began in October 2008. The CSSP has supported Getting Insulin Right in providing funding for a physician champion John Devlin, MD Endocrinologist, project manager Charlotte Bailey-McPherson RN, and diabetes nurse educator Stacey Starbird-Richmond, RN,CDE. This group has worked collaboratively with a multidisciplinary team in development of the insulin order sets and guidelines toward improving glycemic control. Kate Hawley, RD and Rosellen Taylor, RD have been integral in providing evidenced based guidelines and Mike Poulin contributes his expertise with the development of the SCM order sets. The goals: To establish a protocol driven system for improved inpatient glycemic control and enhance transitioning patients to outpatient follow-up care. The aim of the protocol driven order sets are to mimic normal insulin physiologically rather than sliding scale insulin that historically provide extremes of hyper and hypoglycemic levels. Year one of Getting Insulin Right has been to establish subcutaneous, intravenous insulin, and IV transition protocols providing basal, nutritional, and correctional insulin. A hypoglycemia, hyperglycemic tube feeding protocol and TPN guidelines has also been established. Roll out for the new insulin protocols are estimated to be February 2009. Nutritional services have been integral in development of diabetic meal plans enhancing patient and staff carbohydrate awareness. A new menu system listing amounts of carbohydrates in food choices ordered for patients was implemented in July 2008. Moving to intensive basal & nutritional insulin therapy and away from sliding scale insulin is a large culture shift occurring not only at MMC but across the nation. Evidence shows a correlation between improved glucose control and clinical outcomes. Statistics show that 12.4 % of discharges list diabetes as a diagnosis, diabetes is the 4th most common co-morbidity in discharges, occurs in 29% of cardiac surgery patients and can increase length of stay by three days.

  19. IN-PATIENT GLYCEMIC CONTROL PROJECT Staff Ed EDUCATION TIMELINE Stacey Starbird-Richmond RN, CDE, Diabetes Nurse Educator

  20. Getting Insulin Right • Getting Insulin Right 3-hour Class • September 2008- present 2009 • 43 scheduled • 40 held • All shifts • Getting Insulin Right Traveling Fair • 25 offered • 23 held • All shifts • Variety of days & length of time • Pharmacy Classes • 3 held • 7am, 12n, 3:30pm • 60-90 minutes • Pharmacy conference room

  21. Getting Insulin Right • Nutrition RD Classes • June-October 2009 • 3 held • 2 hours • Diet Tech Classes Pending • Basic bedside education • CNA Classes

  22. Unit based vs. Central location Contact hours Length Beverages….. Delivered in a timely fashion!! 3-6 months to roll out Momentum Attendance Sheets Advertising Hospital Communication: Intranet, emails, Net News Bulletin boards Flyers Progressive Signs Communication to Units Reminders Bed Boards Daily Charge nurse meeting Nursing Unit Huddles Classes

  23. GETTING INSULIN RIGHT CLASSES Department of Nursing Contact Paulette Walker walkep@mmc.org or call x2397 to register. FMI: Contact Stacey Starbird-Richmond, RN, CDE Diabetes Nurse Educator at email starbs@mmc.org or call x6047 3 Contact Hours Maine Medical Center Department of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

  24. Three hour RN classes All shifts Several month Monthly Didactic Multiple Case Scenarios Carb Counting Menus Determining Doses Use of calculator for insulin infusion titration Games New Insulin Protocols Evidence Physiology SC protocol IV insulin infusion IV Insulin Transition Hypoglycemia protocol TPN & TF guidelines Steroid guidelines Getting Insulin Right Classes Make interactive! Staff must apply information to real scenarios! Attendance feed back.

  25. Nursing Stats

  26. Nursing Stats

  27. Class Attendance • Presented at Nursing Leadership • Generated increased attendance • Generated 3 hour Class trial on units • Requirement 5-6 registered • Staff to cover each other • Management assisted in coverage • summer months, great effort • Tough, stressful

  28. Examples from class • Utilize case studies • Hands-on • Interactive • Jeopardy • Bingo Critical thinking skills

  29. aspart aspart aspart glargine Basal/ Nutritional Insulin Therapy Breakfast Lunch Dinner Plasma Insulin 4:00 8:00 12:00 16:00 20:00 24:00 4:00 Time

  30. Getting Insulin RightIn review…the pancreas • Releases a continual, low level amount of insulin • providing BASAL • Burst of insulin in response to the rise in glucose after a meal • NUTRITIONAL or prandial • Pancreas responds to and corrects a rise in blood glucose from other sources • CORRECTIONAL

  31. Basal, Nutritional, Correctional • Mrs. McPherson has type 1 diabetes, Hx CABG x3, a-fib • Admitted for r/o MI • What 3 components of insulin should her orders consist of ?

  32. 3 components to mimic normal physiology: Lantus 10 units 2200Basal Aspart 5 units pc Nutritional Scheduled 8am Scheduled 1200 Scheduled 1700 Aspart Correctional 150-200 = 1 units 201-250 = 2 units 251-300 = 3 units 301-350 = 4 units 351-400 = 5 units Basal, Nutritional, Correctional

  33. Lantus 10 units 2200Basal Aspart 5 units pc Scheduled 8am Scheduled 1200 Scheduled 1700 Aspart Scale Correctional 150-200 = 1 units 201-250 = 2 units 251-300 = 3 units 301-350 = 4 units Ms. McPherson is doing well, no angina, taking PO, plans on eating meal BG 11:40 am ac lunch is 227mg/dl What is her total insulin dose? What is total insulin dose to be given?

  34. Answer • What is total insulin dose to be given? • Answer • 5 Nutritional + 2 Correctional • Total dose = 7 units Aspart immediately post meal • Consumed all carbohydrates

  35. Case Study continued • Ms. McPherson received her 7 units aspart post meal at 1215. • Within 10-15 minutes the CNA reports Ms. McPherson vomited. She reports “the Macaroni and Cheese was horrible, upset my stomach”. • Nursing Actions? • Thoughts?

  36. Case Study continued • Answer: • Replace her meal or carbohydrates. • Check total carbs to be replaced • meal ticket • nutrition orders • Aspart will be peaking in 30-60 minutes. • Potential for hypoglycemia

  37. Basal, Nutritional, CorrectionalCase Study continued • Mrs. McPherson continues to have GI complaints. • She continues to vomit and cannot tolerate food or liquid to replace her carbohydrates. • Nursing actions, thoughts?

  38. Basal, Nutritional, CorrectionalCase Study continued • Orders entered for cardiac catherization tomorrow • NPO after 2400 tonight • Maintenance IV NS 100 ml/hr @ 2200 • Should Mrs. McPherson receive her basal dose of Lantus (glargine) tonight at 2200?

  39. Case Study continued • Answer • Yes. She has type 1 DM, needs basal insulin

  40. Tray Ticket Grams of carbohydrate in food item Medium range of total carbohydrate in meal Grams of carbohydrate meal plan ordered

  41. Tube Feeding (TF)Example • Pt on ETF: Jevity 1.2 @ 70 ml/hr • Tolerating at goal. • BG check at 1200 =198 mg/dl. • Patient administered 2.0 units correction + 3.0 units Regular as scheduled with TF. • PEG tube becomes dislodged @ 1430. Considerations and nursing plan? • Answer: • Hang D10 70 ml/hr to replace Dextrose • Prevent potential hypoglycemia • Change of shift: hand-off communication. • Reconnect TF when tube replaced.

  42. Advertising Hospital Communication: Intranet, emails, NetNews Bulletin Boards Flyers Progressive Signs Communication to Units Reminders Bed Rounds Will they come? Raffle entry for gas cards Correct answers Initial Education 7 Poster Boards Evidence, physiology, protocols Case studies Matching Games Test Attendance sheets Time Consuming Attendance low unless mandatory Unit drivers Poor timing with roll out Getting Insulin Right Fairs COMMUNICATION

  43. E-Learns…another bridge • PowerPoint Presentation • In computerized test environment • Utilized hospital wide • Staff “e-learned out” • 4 Modules MMC Insulin Protocols for Nursing • Getting Insulin Right: Basal, Nutritional, Correctional • Getting Insulin Right: Insulin Infusion Protocol & Titration • Getting Insulin Right: Tube Feeding & TPN • Getting Insulin Right: Hypoglycemia • Essentials

  44. NPO Procedure at 1130 0730 BG is 220mg/dl What, if anything should be done? Pharmacy Prandial Aspart daily with breakfast, based on 60-74 CHO meal 6 units, % Carbs eaten 76-100 3 units % Carbs eaten 26-75 0 units % Carbs eaten 0-25 Correctional Aspart tid-meals, PRN BG 150-200 = 1 units 201-250 = 2 units 251-300 = 3 units 301-350 = 4 units Case study continued • Answer • 2 units correctional Aspart - given for BG 220mg/dl • Hold Prandial Aspart – for NPO status

  45. Pharmacy Prandial Aspart daily with lunch, based on 60-74 CHO meal 6 units, % Carbs eaten 76-100 3 units % Carbs eaten 26-75 0 units % Carbs eaten 0-25 CorrectionalAspart tid-meals, PRN BG 150-200 = 1 units 201-250 = 2 units 251-300 = 3 units 301-350 = 4 units Mrs. Potts returns from procedure at 1315. Box lunch given. “Hungry, I’ll see what I can eat.” BG ac meal is 312mg/dl. Nursing Plan? How will you determine how much Aspart to administer? Case study continued • Answer: • 4 units correctional Aspart now. • Ask Ms. Potts or family to ring bell • Return within 20 minutes to estimate • CHO consumed against total CHO in • box lunch tray ticket. • Administer prandial aspart post meal • based on % of carbs eaten.

  46. Case study continued • You return in 15 minutes • Mrs. Potts consumed 100% of her 60-74gm carbohydrate (CHO) meal plan • You already administered 4 units correctional aspart for BG of 312mg/dl Pharmacy: Insulin Aspart injection Subcutaneous, Aspart daily with lunch, based on 60-74 CHO meal • 6 units, % Carbs eaten 76-100 • 3 units % Carbs eaten 26-75 • 0 units % Carbs eaten 0-25 How much insulin do you administer? ANSWER 6 units prandial aspart Chart actual time given

  47. SC Protocol Practice • Type 2 DM, A1C 10.2%, LE ulcer. Antibiotics. • “stomach upset” • 45-59 gm CHO/meal • Breakfast tray arrives • Ac breakfast BG at 0815 of111mg/dl Considerations & Insulin plan for patient? ●Return within 20 minutes ●Review tray ticket for total CHO amount vs % CHO eaten ●Administer aspart dose based on CHO consumed. • Pharmacy • Prandial Aspart daily with breakfast, • based on 45-59 CHO per meal • 4 units, % Carbs eaten 76-100 • 2 units % Carbs eaten 26-75 • 0 units % Carbs eaten 0-25 • CorrectionalAspart tid-meals, • PRN BG • 150-200 = 2 units • 201-250 = 4 units • 251-300 = 6 units • 301-350 = 8 units

  48. SC PracticeTray Ticket-Grams of Carbohydrate • 1 Slice Toast wheat (16g) • 1 Each Diet Jelly (6g) • 1 Each Margarine (0g) • 1 ½ Banana ½ (13g) • 1 Box Cheerios (13g) • 1 8oz Skim milk (12g) • How many total carbohydrates are on the tray? • How many total carbohydrates were consumed? approximately 50% of the carbohydrates consumed Patient consumes the toast & banana 60 gm CHO 29 gm CHO

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