Safe Implementation of a Hyperglycemic Crises Protocol by Utilizing a Conversion Table

Purpose: Diabetic ketoacidosis (DKA) and Hyperosmolar hyperglycemic state (HHS) are medical emergencies associated with increased morbidity, mortality and healthcare costs (Joslin, 2013). Prompt identification and proper management of these emergencies are imperative to improve patient outcomes and prevent death (Juneja, et al., 2009). Intravenous (IV) insulin is adopted for treatment of hyperglycemia in the critical care setting (DeSalvo, Greenberg, Henderson, & Cogen, 2012;ADA, 2017;Kreider & Lien, 2015). Its use is renowned for positive clinical outcomes however the risk of hypoglycemia and its accompanying negative sequelae are inherent. IV insulin drips necessitate enhanced critical thinking skills, vigilant monitoring of lab values, titration of fluid, electrolytes and insulin. Methods: An interprofessional collaborative effort, based on evidenced based studies (DeSalvo, Greenberg, Henderson, & Cogen, 2012;Myers, Zilch & Rodriquez,2013) developed and sought to pilot a hyperglycemic crises protocol (on the critical care units) that facilitated an appropriate and timely management of patients presenting with DKA or HHS. Such interventions contribute to length of stay reductions and associated complications of an ICU admission. Every effort to restore patients to diabetic control must be advocated for. Preliminary hyperglycemic crises protocol drafts, piloted on critical care units, required nursing estimation for insulin titration thus impacting accuracy and patient safety. This latter practice could have had the potential to cause nurses to erroneously administer IV insulin drips. Immediate efforts to address this injurious practice were necessitated prior to patient harm occurrence. This hyperglycemic crises protocol was presented to the nursing critical care collaborative council, an interdisciplinary team, for consideration, input, approval and stakeholder buy-in. The Chief Nursing Officer strongly advocated for clarification regarding scope of practice regarding IV insulin titration, by registered nurses, in the ICU setting. As a response, the New York State Office of Professional Licensure indicated that these tasks are definitely within critical care nurses scope of practice when accompanied by the facility to decrease medication errors. Results: A conversion table was developed in order to assure accuracy of insulin drip calculation while fostering an environment of safety for both staff and patients alike. Buy- in from staff was essential in the successful implementation of the pilot program which lead to the establishment of the protocol as an adjunct in the clinical management of patients presenting with DKA and HHS. Resulting evidence included decreased length of stay – which facilitated availability of precious ICU beds for other patients that warranted a higher level of care and decreased incidence of hypoglycemia in DKA or HHS patients admitted to the ICU. Ongoing nursing education and competency evaluation is maintained annually via skills fairs, briefs and huddles. Still medical direction regarding transition from insulin drip to subcutaneous insulin has caused confusion within the ranks of novice physicians. It has been noted that the young MD’s were not trained in the half life of regular insulin in the IV nor the onset of action of intermediate or basal insulin. Previously trained ICU nurses were called upon to explain. Conclusion: The resulting outcomes indicate decreased length of stay -facilitated availability of precious ICU beds for patients that warranted a higher level of care and decreased incidence of hypoglycemia in patients with these diagnoses admitted to the ICU.