Health Professions Act

Revised Hypoglycemia Protocol

Insulin Subcutaneous Sliding Scale

Anar Dossa BScPharm CDE

September 14, 2007

HPA-Health Professions Act

What is it?

Regulatory framework for health

professionals
Basic requirements for regulating every
health profession are similar

Accountability for standards of practice

Quality assurance measurements
Rigorous registration process
Mechanism to review public concerns

HPA-Health Professions Act

Nursing Implications

Increase in scope of practice for

registered nurses effective July 1, 2006
Allows registered nurses to initiate certain
patient care activities without a doctors
order

HPA-RN Scope of Practice

WITHIN SCOPE

CRNBC
CERTIFIED
PRACTICE
OUT OF
SCOPE

Nursing practice
activities

Vital signs
Not reserved
actions
Current Practice

Reserved actions Reserved

Reserved
without an order actions with actions for
an order
CRNBC
certified
Hypoglycemia:
practice
initiate IV access
& medications

Section 8
July 1, 2006

Reserved
actions
outside
scope of
practice

NP &
Section 9 Section 10
Delegated
July 1,
August
Fn
2006
2007

CRNBC Standards, Limits & Conditions

crnbc 2006

Controls on Practice

CRNBC 2006

Provincial Pilots
VCH:

Hypoglycemia, Wound Care,

IV, Tylenol, Oxygen,Catheter

IHA:

Venipuncture initiation

NHA:

Catheter initiation

VIHA:

Oxygen initiation

FH

Wound Care

Hypoglycemia Protocol

Hypoglycemia is defined as blood sugar

less than

Hypoglycemia Protocol

Risk factors for hypoglycemia

Nutritional status

Missed meals, delayed meals

Heart failure, renal or liver disease

Malignancy
Sudden reduction of steroid dose
Altered ability of patient to report symptoms
Vomiting

Hypoglycemia Protocol

Risk factors for hypoglycemia

New NPO status

Reduction in IV dextrose
Unexpected interruption of feeds/TPN
Altered consciousness from anesthesia
Advanced age
Previous history of severe hypoglycemia

Symptoms

Variable from patient to patient

Assess patient for his/her individual

symptoms

Symptoms

Trembling
Palpitations
Sweating
Anxiety
Nausea
Hunger
Tingling

Clinical Practice Guidelines Can J Diabetes Dec 03

www.diabetes.ca

Symptoms

Confusion
Difficulty concentrating
Weakness
Drowsiness
Vision changes
Difficulty speaking
Headache
Dizziness
Tiredness

Clinical Practice Guidelines Can J Diabetes Dec 03

www.diabetes.ca

Symptoms

Night

Crying out
Night sweats
Morning headache
Nightmares

Symptoms-severe

Unresponsive
Unconscious
Coma
Seizure

Hypoglycemia Unawareness

No warning signals
First sign may be loss of consciousness
Confusion

Hypoglycemia in the Elderly

Reduced release of epinephrine and

glucagon
Cognitive impairment

May not be able to communicate in timely

manner

Beta-blockers and Hypoglycemia

What is the concern?

Not an absolute contraindication

Hypoglycemia Protocol

Section A

Conscious and able to swallow

Section B

Conscious but NPO or unable to swallow

Tube fed/TPN

Section C

Unresponsive, unconscious, seizuring

Where will these items be kept?

D10W

D50W

Omnicell machine

Glucagon

Stores item, units to order via stores

Omnicell machine

Dextrosol

Stores item

NIA Section 8: Hypoglycemia

S e c tio n 8 (1 ) P e r fo r m v e n ip u n c tu r e fo r th e p u r p o s e o f:
E s ta b lis h in g in tr a v e n o u s a c c e s s , m a in ta in in g p a te n c y o r m a n a g in g h y p o g ly c e m ia
A d m in is te r a s o lu tio n b y in s tilla tio n p a r e n te r a lly .

R N A s s e s s P t.
D ia g n o s e C o n d it io n

C o n d itio n :
H y p o g ly c e m i a
P o l ic y / P a t i e n t C a r e G u i d e li n e
N u r s e In itia te d A c tiv ity :
D ocum ent A ssessm ent
I n it ia t e G lu c a g o n o r I V in s e r t io n
I V S o lu t io n

C o n tr a in d ic a tio n s :
PCG

C o n t a c t P h y s ic ia n

P h a rm a c y :
P r o c e s s e s N IA
R e c o rd s G lu c a g o n
o r D 5 0 W o n M A R

R N a c c o u n t a b le to a n t ic ip a t e &
m o n it io r o u t c o m e s

P h y s i c ia n a w a r e w i t h i n 4 h r s

Follow Up

Why did hypoglycemia occur?

Should the dose of insulin or oral agent be
adjusted?

Insulin Subcutaneous Sliding

Scale

Refer to pre-printed order

When should an insulin sliding

scale be used?
Supplement

regularly scheduled
insulin or oral diabetes
medications
May

be used as a dose finding

strategy
Goal

is to use as little sliding

scale insulin as possible

When should this sliding scale not

be used?

Diabetic ketoacidosis
Intravenous insulin

Insulin Sliding Scale

Scheduled insulin plus

Supplemental insulin

Correction-dose insulin
Dose-finding strategy
Accommodate rapid changes in insulin
requirements
If correction doses are frequently required,
change scheduled dose

Which sliding scale?

Low
Intermediate
High
Custom

Low

Low or unknown insulin resistance

High or unknown insulin sensitivity

How do you determine this?

Insulin Resistance Determination

Insulin Dose
(Total Daily Dose)

Resistance Level

< 0.5 units/kg

Low

0.5 1 unit/kg

Intermediate

> 1 unit/kg

High

Low Resistance

Thin
NPO
Renal Failure
Elderly

High Resistance

Obese

Insulin Sliding Scale

Always use regular insulin

Do not give at hs

Why?
Exception

See protocol

Follow Up

Evaluate total dose q24-48hrs

Does the basic dose need to be adjusted?

New Insulins on Formulary

Insulin Aspart

NovoRapid
Rapid acting insulin analogue
Bolus insulin

Insulin Glargine

Lantus
Long acting insulin analogue
Basal insulin

Insulin Aspart

Must be given immediately prior to meals

Within 15 minutes
Risk of hypoglycemia if meal is delayed
Can be mixed with NPH as long as the
manufacturer is the same
Inject immediately after mixing
Cannot be given IV

Insulin Glargine

Cannot be given IV
Clear solution

Cannot be mixed with anything

Do not confuse with regular or aspart

Formulary Status

Both insulins are restricted

Endocrinology

For Type 1 patients who experience hypoglycemia

or inadequate control on Regular/NPH

For patients on these insulins prior to

admission

Action Profiles of Bolus & Basal

Insulins
lispro/aspart 46 hours
Plasma Insulin levels

regular 6-10 hours

BOLUS INSULINS
BASAL INSULINS

NPH 1220 hours

detemir ~ 6-23 hours (dose dependant)
glargine ~ 20-26 hours

Hours

Note: action curves are approximations for illustrative purposes. Actual patient response will vary.
Mayfield, JA.. et al, Amer. Fam. Phys.; Aug. 2004, 70(3): 491
Plank, J. et.al. Diabetes Care, May 2005; 28(5): 1107-12

Insulin Comparison
Insulin

Onset Peak
(hrs) (hrs)

Durn
(hrs)

Cost
Pcare
per mL Covge

Aspart

5-15* 1-2

3-5

$2.30

Partial

Regular 0.5-1 2-4

6-8

$1.24

Yes

NPH

1-2

6-12

18-24

$1.24

Yes

Glargine 2-4

No
peak

20-24

$5.51

SA**

*minutes **special authority

Insulin Mixing

Regular and NPH

OK to mix
Resuspend NPH
Inject adequate amount of air into NPH
Withdraw regular into syringe first
Then withdraw NPH
What if you dont do it this way?

Questions?