NPO patients awaiting tests. When patients are NPO [nil per os, or nothing by mouth], they can be at an increased risk for hypoglycemia; however, if patients are properly dosed on basal/bolus regimens, only the bolus dose should be held when they go NPO.
“Nurses must be taught not to hold basal just because a patient is NPO,” Dr. Rogers says. “However, we sometimes see institutions with an overreliance on basal insulin compared to bolus doses, to the point that the basal dose is covering some nutritional needs. This could increase risk for hypoglycemia if continuing basal insulin at full dose when NPO.”
If there is a 50-50 split between basal and bolus insulin, then it should be safe for patients to continue their full basal insulin when they’re NPO, although some institutions choose to halve this dose for patients who are NPO. Basal insulin should not be routinely held, however. Each institution should standardize its practice in these instances and write them into insulin order sets.
“We try to explain that [those inpatients newly diagnosed] must tend to their disease every day. I think we lose a lot of folks at this crucial point, and those patients end up being readmitted. In addition, their ability to obtain medications and adhere to regimens is quite difficult.”—Joshua D. Lenchus, DO, RPh, FACP, SFHM, hospitalist, associate professor of medicine and anesthesiology, University of Miami Miller School of Medicine
Monitoring and adjusting blood sugar. Dr. Rogers finds that many physicians and nurses don’t recognize high as problematic. “Often physicians don’t even list hyperglycemia or hypoglycemia as an issue in their notes, and adjustments are not made to medications on a daily basis,” he says.
Nurses perform four CBG readings on eating patients throughout the day, and patients on a basal/bolus regimen receive four doses of insulin. “Each dose of insulin is evaluated by one of these blood glucose monitoring values,” he says. “This allows for customized tailoring of a patient’s needs.”
Dr. Rogers says some hospitals administer the same insulin order three times a day with every meal. “Patients may vary in their nutritional intake, and their insulin should be customized to match,” he maintains. “There should be separate insulin orders for each meal to allow for this.”
The biggest issue related to this is that physicians don’t make changes to insulin doses on a daily basis in uncontrolled patients—which he would encourage. There are different methods to achieve this. Dr. Rogers would suggest adding up the amount of correction scale insulin the patient received the previous day and appropriately redistributing this within the scheduled basal and bolus doses.
Listen to Dr. Rogers’s advice to hospitalists when working as part of a quality team in achieving glycemic control.
Endocrinologists at UC San Diego stress the importance of performing point of care blood glucose testing within 30 minutes before a meal. This is important in order to calculate an appropriate dose of correction insulin. “We provide a lot of education regarding timing and clinical assessment of the value,” Dr. Kulasa says. “If a value seems like an outlier, nurses should question whether it’s an erroneous sample and if they should repeat the test or if there is a clinical scenario to explain the outlier, such as recent snack or interruption in tube feeds.”
Medication reconciliation. A big mistake is to continue a patient’s in-hospital treatment regimen at discharge. The discharging physician should reevaluate an outbound patient, Dr. Rogers says, and prescribe treatment based on what the patient took prior to admission.
Dr. Kulasa says the inpatient team should make medication adjustments based on a patient’s hemoglobin A1c and the amount of insulin a patient required in the hospital, as well as any changes that might occur upon departure. Does the patient have an infection that’s improving? Is the patient tapering steroids at discharge? These factors should be considered when making adjustments. “We get a lot of information during the inpatient stay that we need to account for when designing an outpatient regimen,” she says.