Maine Medical Center Portland, Maine Kate Hawley, LD

1. Maine Medical CenterPortland, MaineKate Hawley, LD Kathy received her bachelor’s degree in Nutrition from the University of Maine at Orono, and her masters’ degree in Adult Education from the University of Southern Maine. She is a Registered/Licensed Dietitian. Kathy presently works as the Manager of the Maine Medical Center Department of Clinical Nutrition and Patient Services. Kathleen Halpin, MS, RD/LD Kate Hawley graduated from the University of Rhode Island with a degree in Dietetics and became a licensed dietician in 2006. She is currently working as a Clinical Dietician at Maine Medical Center covering surgical and prenatal care units. Kate specializes in inpatient diabetes management and has been working with the multidisciplinary team to develop the MMC glycemic protocols.

2. “Integrating Carbohydrate Counting into your Insulin Protocols” Kathy Halpin, MS, RD/LD Kate Hawley, RD/LD

3. Objectives Discuss our experience with converting to CHO controlled diet Share MMC nutrition services experience with implementing/role in insulin protocols Suggestions/thoughts as to how your nutrition department can aid in developing protocols

4. Brainstorming Determine if what you have works or does not work Get opinions from staff members outside your department Do you have the resources to make a change If you do want to make a change carefully assess what will work best Will your administration support a change ?

5. Will a change create a better outcome? Is it effective in aiding in better glycemic control? Consider all factors: hospitals current policy/practice on glycemic control (?uniform/standardized), compliancy to diet order (patient or nutrition department), causes of hyperglycemia Is it user friendly: Nursing, Physicians, Patients, nutrition services Will it be compatible with insulin protocols? Does it assist patients in transition to home management Do you have support from administration if change is necessary

6. Why change to CHO controlled diets ? Research from hospital protocols, DB research studies and patient outcomes indicates it is the best approach for optimal glycemic control Will the system be compatible for your system/hospital Give examples Easier for prandial insulin dosing Current trend for diet management of diabetes Patient education, facilitate transition to out patient management

7. Accountability Menu audits for compliancy to current system- Are we really complying with diet Rx? Initial Tray Audits for calorie controlled diets 65 menu/tray tickets audited 2400, 2000, 1800, 1600, diabetic diet 50% compliant 50% non-compliant

8. What did MMC decide to do???? Change to CHO controlled diets using the hospital’s electronic system, Sunrise Clinical manager, and interfacing this with the Nutrition departments electronic system called CBORD.

9. Decide on the diet orders Enter parameters for the diet orders into CBORD Compliances and Pattern Fixing CBORD Steps ½ portions may be an option Evaluate the recipes and each food item All food items and recipes portions need to be weighed Adjust portions sizes as needed

10. Calories & CHO

11. Work in conjunction with your IS department to get diet orders into the hospital system • Train staff and emphasize need to follow recipe and portion size – staff will need all the right tools • i.e. various scoops, spoodles, scales etc. • Continuously emphasize to the production staff the importance of the accuracy when preparing or serving food. • Communicate Communicate Communicate

12. Pattern Fixing Pattern Fixing is a CBORD functionality that ensures the number of CHO gms on each meal tray ticket is not too high or low. The CBORD system adjusts patient meal selections so that a meal’s nutrient or dietary exchange totals match the patient’s prescribed diet order.

13. Pattern Fixing Example: Patient dietary goal pattern = 45 gm at breakfast, lunch, dinner- yet the patient selects foods totaling 75gm carbohydrates. Results: The system will remove food item(s) to bring the CHO gms within the limits of the diet order.

14. Once all the steps were completed with the CBORD system it was time to test the system and view the tray tickets ! What would they look like ?

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

16. Post implementation of the CBORD Describe our menu audit system Show our menu audits Share with staff Quarterly meetings with NCRs

18. Begin Department Staff Training Identify which staff need to be trained Sample of training topics Hospital program What is Diabetes ? Diet orders Role responsibilities Portion Control

19. Essential items to include in the training Imperative to Share with staff ‘WHY’ CHO counting is essential, DO NOT minimize the importance Bring in what may hit them personally Discuss how correct portions impact the budget Administration will also like this one Portion control Power Point House wide on how utilize + order (Nursing, Physicians)

20. Two Teams working for the same Goal Nutrition Team CSSP DB TEAM

21. MMC Insulin Protocols Nutrition Departments role in the creation and implementation

22. Nutrition Role with Protocol Development Integral part of the development team Education Physician’s, RNs, CNAs, RDs Responsible for the implementation of CHO controlled diets- ~50% of insulin needs

23. Hyperglycemia at MMC: New insulin order sets Basal Insulin Nutritional Insulin Correctional Insulin SC protocol IV insulin & transition Hypoglycemia protocol TPN & TF insulin guidelines Steroid insulin guidelines

24. Normal patterns of insulin release from the pancreas during course of a day Breakfast Lunch Dinner Plasma Insulin 4:00 8:00 12:00 16:00 20:00 24:00 4:00 Time

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

26. Continuous TF Short Acting Insulin For continuous coverage of CHO in TF q 6 hours 0600 1200 1800 2400

27. Education: Basal, Nutritional, Correctional Nutritional or Prandial Insulin Insulin required at meal-time Covers rise in blood glucose after carbohydrates Amount of insulin necessary to cover: TPN, ETF, nutritional supplements, or meals In general: 1 unit per 15 grams Lowers BG back to desired target post Carbohydrate infusion/ingestion Hold nutritional insulin if patient is NPO

28. RN education: Elements of CHO Counting Learn how to relate carbohydrate intake to blood glucose levels Focus on total carbohydrate versus types of carbohydrate TF and TPN provides significant source of CHO Foods with carbohydrate CHO needs are individualized

29. Fact Sheets for Nursing Nursing will need the CHO content of various food items to determine amount of prandial insulin to administer Nourishment In between supplements Box meals Enteral products Foods from the outside

30. NOURISHMENTSOctober 2009

31. SC ProtocolNutrition ◊When do trays arrive on your unit? ◊ How will you know ? ◊ Which patients require insulin ? ◊ Entire meal? ◊ Insulin based of CHO consumed ◊ Plan to follow up on CHO consumed? ◊ Partnership Patient, Nurse, CNA, Nutrition

32. RD role in team approach developing protocols Representative from nutrition department, Resource for PO, TF, and TPN protocol development Education Support for post implementation follow up evaluation

33. Implementation of Protocols Support staff (nutrition) need to be available for RN and MD questions Nutrition staff evaluating appropriateness of diet ordering- RD to notify MD if change in diet is needed Nutrition staff available on patient care unit at meal times

34. Points of discussion Support Champion physician and administration Room service vs. Scheduled tray delivery Appropriateness of diet orders Nursing time constraints at meals Can nutrition assist? Resources for implementation Budget, staffing Emphasis on inter-department communication Work on most common scenarios (i.e. TF protocols- can’t make protocols for every scenario)

35. Research: Nutrition Role in Education to Nursing Staff “Carbohydrate counting education to nursing in preparation for implementation of an insulin protocol” Kate Hawley RD, LD and Sharon Tate MS, RD, LD • Evaluate education provided by dietitians to nursing staff in preparation for the implementation of new insulin protocols. • Future topics

36. Breakout Session What is your facility currently practicing for glycemic control at meal times? How would you improve prandial glycemic control at your hospital?

37. Thank You for the opportunity for us to share our program we hope it inspires you to evaluate yours. THOUGHTS, OPINIONS AND QUESTIONS ???