Resident s Guide to Inpatient Diabetes

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Alison Owen
10 years ago
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1 Resident s Guide to Inpatient Diabetes

2 1. All patients with diabetes of ANY TYPE, regardless of reason for admission, must have a Hemoglobin A1C documented in the medical record within 24 hours of admission OR within the last 90 days prior to admission. Patient report of Hemoglobin A1C is not acceptable. Also, height, weight and BMI must be documented on all Admissions. 2. The type of diabetes must be documented in the medical record. DM type 1, DM1, DM type 2, DM2, suspected DM1 or 2, CF associated,cfrd, medication associated are correct diagnoses. Incorrect: IDDM, NIDDM, Diabetes, Diabetes Mellitus, DM, Borderline ALWAYS USE DIABETES ADMISSION/TRANDSFER ORDER SET!!!! NO INDIVIDUAL ORDERS. 3. Patients with DM1 or DM2 must be on a Pediatric Diabetic Diet. Do not place them on a low fat diet, a level 1, 2, or 3 diet, or any other type of diet unless medically necessary. 4. blood glucose monitoring is before meals, at bedtime, and 2 am. 5. Once DKA is corrected, IV fluids are generally not needed unless the patient is not drinking, ketonuria is still present, or electrolyte issues persist (hypokalemia). 6. If the patient is transferring from the PICU to floor status, the patient must have Diabetes Admission/Transfer Orders completed. Please use the order set in EPIC. DO NOT place individual orders as there are specific nursing instructions associated with the order set, that will be missed if not used. EX:If the patient has been transitioned using NPH at breakfast, DO NOT cover lunch CHO with insulin, as the NPH will be peaking at that time. 7. All children who attend school must have school forms completed prior to discharge. Forms are county specific and are located in Clinician Order Forms CH Endocrinology Service Specific Discharge Form Calculating Basal/Bolus insulin regimen Lantus(Glargine) Insulin- Is usually given at bedtime. Lantus cannot be mixed with any other type of insulin! Novolog(Aspart), Humalog (Lispro) or Apidra (glulisine) insulins- Novolog/Humalog dose is generally given using an insulin to carbohydrate ratio. You calculate insulin to be given as 1unit per X grams carbohydrate eaten. It is usually given after meals in infants/toddlers. The child should complete the meal in minutes and dose should be calculated and given. If you are sure of the amount of food that will be eaten, as in older children, the meal insulin should be given before the meal. *Note: We only have insulin aspart (Novolog) on formulary Calculating Lantus Dose- The initial dose is based on weight. Start with unit per kg in newly diagnosed lean children, to determine the total daily dose (TDD). Half of the TDD will equal the Lantus dose. If the child is on another type of insulin and will be switched to Lantus, take ½ of previous TDD to equal Lantus dose. Calculating bolus(rapid acting) insulin to carbohydrate ratio- there are two methods used in Pediatric Endocrinology.

The type of diabetes must be documented in the medical record. DM type 1, DM1, DM type 2, DM2, suspected DM1 or 2, CF associated,cfrd, medication associated are correct diagnoses.

3 1. The other options to calculating ratio is: The 450 rule- take 450 divided by the TDD this will be the ratio. The 500 rule (500 /TDD) may also be used. 2. You can calculate the total grams of carbohydrate eaten in a day and divide by ½ of total daily insulin dose (or ½ calculated TDD using weight). This will give you the insulin carb ratio that you will use to come up with meal dose of insulin. Calculating correction dose insulin: Use bolus (rapid acting) insulin before meals if it has been at least 3 hours since last meal, snack, or correction dose. For blood glucose >150 use (for children over 13 years old) For blood glucose > 200 use 3% TDD (total daily dose) For blood glucose > 250 use 5% TDD For blood glucose > 300 use 7.5% TDD For blood glucose >350 use 10% TDD As a general rule, we do not give correction insulin for blood glucose less than 250 in infants/toddlers. We rarely cover hyperglycemia at night unless there are moderate to large ketones.

This will give you the insulin carb ratio that you will use to come up with meal dose of insulin.

4 Prescription List Please use EPIC ALLOW SUBSTITUTION Order scripts for newly diagnosed patients on day one. Medicare patient scripts must be printed on blue prescription paper. *All new diagnosis patients will receive VIALS and SYRINGES, pens will not be prescribed to newly diagnosed patients. They can transition in follow-up. Prescription Glucose Meter Refills: 0 Brand per Insurance preference Dispense: 1 meter Glucose Meter Test Strips Refills: 5 Brand per insurance Preference Dispense: 200 strips to test blood sugar 4-6 time daily Lancets Refill: 5 Brand per insurance Preference Dispense : 200 lancets to test blood sugar 4-6 times daily Lantus or Levemir Refills: 5 Per insurance preference Dispense: Vials Directions: units qhs by subcutaneous injection Novolog or Humalog or Apidra Refills: 5 Brand per insurance preference Directions: 1 unit: grams CHO by subcutaneous injection Dispense: 2 vials (1 for home, 1 for school, daycare or work) Insulin syringes BD with ultrafine needle Refill: 5 unit syringes Dispense: syringes for insulin injection 4-6 times daily Ketostix Refill: 5 Dispense: _2 bottles ( 1 for home, 1 for work, school or daycare) Directions: Check urine for ketones if BG is over 240. Notify Endocrine clinic if Ketones are moderate to large. Glucose Tablets (4 grams/tablet) Refill: 5 Dispense: _2 bottles ( 1 for home, 1 for work, school or daycare) Directions: 4 tablets orally for BG less than 70. Recheck blood sugar in 15 minutes. Repeat if blood sugar is still less than 70. Glucose Gel (15 grams/tube) Refill: 5 Dispense: 2 tubes ( 1 for home, 1 for work, school or daycare) Directions: 1 tube orally for blood sugar less than 70. Recheck the blood sugar in 15 minutes. Repeat the treatment if blood sugar is less than 70. Glucagon Emergency Kit Refill: 1 Dispense: 2 kits ( 1 for home, 1 for work, school or daycare) Directions: mg by intramuscular injection ( syringe) Notes Patient needs to go home with 2 meters (1 home, 1 school) 1 vial = 1000 units 1 vial = 1000 units Options: 30u with ½ markings 50u and 100u Order for children 4 years and older wt > 20 kg give 1 mg (whole syringe) wt < 20 kg give 0.5 mg (half syringe)

5 *The following can be ordered as a re-order or for newly diagnosed patients that have had preapproval from the Endo team. Insulin Pen needles ultra fine 31 gauge 5mm Refill: 5 Dispense: 200 needles for insulin injection 4-6 times daily Lantus pens Refills: 5 Dispense: 1 box Directions: units qhs by subcutaneous injection Novolog or Humalog pens Refills: 5 Dispense: box Order only if insulin pens are ordered. If ordering Pens, syringes may not be needed. Order pen needles. If ordering Pens, syringes may not be needed. Order pen needles. Send ALL scripts on EPIC to Rutledge Tower and then *reorder* them to send to the patient s home pharmacy, also on EPIC Newly diagnosed patients will need two full set of prescriptions. One set sent to Rutledge Tower the other to the patient s home pharmacy. Newly diagnosed patients cannot be discharged until we see the entire order. If a weekend is coming up, make sure prescriptions are sent to Rutledge Tower pharmacy by Friday morning. If patient is admitted on Friday afternoon and is suspected to leave prior to the following Monday, ALL scripts must be received by RT no later than 0800 on Saturday am. For known diabetic patients, always ask if they have all supplies needed. If not they will need prescriptions for whatever they lack. Discharge Appointments: Make three discharge appointments on the day of ADMISSION (M-F) 2 weeks AFTER discharge with the Diabetes Educator (CDE) (1) 6 weeks AFTER discharge the CDE appointment with MD (2) AND Dietician (3)

injection Novolog or Humalog pens Refills: 5 Dispense: box Order only if insulin pens are ordered. If ordering Pens, syringes may not be needed. Order pen needles.

6 **Helpful hints** 1 vial = 1000u of insulin. Calculate total long-acting monthly need by multiplying nightly dose by 31 days. If this is more than 1000u then the patient will need 2 vials monthly. If more than 2000u then patient will need 3 vials monthly and so on. Calculate total short-acting monthly need by using the highest amount of inulin possibly needed. Divide total CHO grams daily (usually 180) by their ratio. Then multiply their highest correction value by 5. Add together, multiply by 31days. Ex: Pt on 1:5 insulin:carb ratio. Eating 180g CHO daily. Correction scale is 2,4,6,8,10. So.180/5=36..10x5= =86 86x31=2,666u per month possibly needed. So patient would need at least 3 vials on short acting insulin monthly. Based on the patient s dose per injection you would need to order the correct syringes. Syringes come in 30u/0.3mL(with and without ½ unit markings), 50u/0.5mL and 100u/1.0mL. All patients will need 30u with ½ unit markings as well as their need for their Lantus dose. If patient is on >30u Lantus then patient will need 50u/0.5mL syringes, if >50u then 100u/1.0mL syringes.

Divide total CHO grams daily (usually 180) by their ratio. Then multiply their highest correction value by 5. Add together, multiply by 31days. Ex: Pt on 1:5 insulin:carb ratio. Eating 180g CHO daily.

INPATIENT DIABETES MANAGEMENT Robert J. Rushakoff, MD Professor of Medicine Director, Inpatient Diabetes University of California, San Francisco

INPATIENT DIABETES MANAGEMENT Robert J. Rushakoff, MD Professor of Medicine Director, Inpatient Diabetes University of California, San Francisco CLINICAL RECOGNITION Background: Appropriate inpatient glycemic