Health Professions Act

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• Health Professions Act
• Revised Hypoglycemia Protocol
• Insulin Subcutaneous Sliding Scale

Anar Dossa BScPharm CDE September 14, 2007
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HPA-Health Professions ActWhat 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

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HPA-Health Professions ActNursing 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

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HPA-RN Scope of Practice
WITHIN SCOPE
CRNBC CERTIFIED PRACTICE
OUT OF SCOPE
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Controls on Practice
CRNBC 2006
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Provincial Pilots

• VCH Hypoglycemia, Wound Care, IV, Tylenol,
  Oxygen,Catheter
• IHA Venipuncture initiation
• NHA Catheter initiation
• VIHA Oxygen initiation
• FH Wound Care

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Hypoglycemia Protocol

• Hypoglycemia is defined as blood sugar less than

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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

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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

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Symptoms

• Variable from patient to patient
• Assess patient for his/her individual symptoms

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Symptoms

• Trembling
• Palpitations
• Sweating
• Anxiety
• Nausea
• Hunger
• Tingling

Clinical Practice Guidelines Can J Diabetes Dec
03 www.diabetes.ca
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Symptoms

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

Clinical Practice Guidelines Can J Diabetes Dec
03 www.diabetes.ca
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Symptoms

• Night
• Crying out
• Night sweats
• Morning headache
• Nightmares

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Symptoms-severe

• Unresponsive
• Unconscious
• Coma
• Seizure

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Hypoglycemia Unawareness

• No warning signals
• First sign may be loss of consciousness
• Confusion

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Hypoglycemia in the Elderly

• Reduced release of epinephrine and glucagon
• Cognitive impairment
• May not be able to communicate in timely manner

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Beta-blockers and Hypoglycemia

• What is the concern?
• Not an absolute contraindication

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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

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Where will these items be kept?

• D10W
• Stores item, units to order via stores
• D50W
• Omnicell machine
• Glucagon
• Omnicell machine
• Dextrosol
• Stores item

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NIA Section 8 Hypoglycemia
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Follow Up

• Why did hypoglycemia occur?
• Should the dose of insulin or oral agent be
  adjusted?

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Insulin Subcutaneous Sliding Scale

• Refer to pre-printed order

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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

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When should this sliding scale not be used?

• Diabetic ketoacidosis
• Intravenous insulin

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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

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Which sliding scale?

• Low
• Intermediate
• High
• Custom

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Low

• Low or unknown insulin resistance
• High or unknown insulin sensitivity
• How do you determine this?

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Insulin Resistance Determination
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Low Resistance

• Thin
• NPO
• Renal Failure
• Elderly

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High Resistance

• Obese

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Insulin Sliding Scale

• Always use regular insulin
• Do not give at hs
• Why?
• Exception
• See protocol

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Follow Up

• Evaluate total dose q24-48hrs
• Does the basic dose need to be adjusted?

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New Insulins on Formulary

• Insulin Aspart
• NovoRapid
• Rapid acting insulin analogue
• Bolus insulin
• Insulin Glargine
• Lantus
• Long acting insulin analogue
• Basal insulin

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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

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Insulin Glargine

• Cannot be given IV
• Clear solution
• Do not confuse with regular or aspart
• Cannot be mixed with anything
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  

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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

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Action Profiles of Bolus Basal Insulins
lispro/aspart 46 hours

• BOLUS INSULINS

• BASAL INSULINS

regular 6-10 hours
NPH 1220 hours
detemir 6-23 hours (dose dependant)
Plasma Insulin levels
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
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Insulin Comparison
minutes special authority
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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?

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Questions?