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Care Gaps in the Administration of Prandial
Insulin for Medical Inpatients
Shannon M. Ruzycki, MD, FRCPC, Kirstie C. Lithgow, MD, FRCPC, Karmon E. Helmle, MSc, MD, FRCPC, Kara A. Nerenberg, MD, FRCPC
About the Authors
Shannon M. Ruzycki and Kara A. Nerenberg are with the Division of General Internal Medicine, Department of Medicine, University
of Calgary, Calgary, AB, Canada
Kirstie C. Lithgow and Karmon E. Helmle are with the Division of Endocrinology and Metabolism, Department of Medicine, University
of Calgary, Calgary, AB, Canada
Corresponding Author: kclithgo@ucalgary.ca
Submitted: October 29, 2018. Accepted: June 3, 2019. Published: August 31, 2019. DOI: 10.22374/cjgim.v14i3.329
ABSTRACT
Background
Inpatient hyperglycemia is associated with multiple adverse outcomes. Lack of coordination
between mealtimes and insulin delivery can worsen glycemic control. Logistical challenges at a
systems level effecting the timing of insulin administration have not been examined.
Local Problem
Previous research identified difficulties coordinating prandial insulin delivery with mealtimes
as a barrier to in-hospital euglycemia.
Aim
Characterize the process of prandial insulin delivery to identify care gaps.
Methods
Process mapping was used to describe the prandial insulin delivery on a medical inpatient unit.
Nurses were surveyed to identify perceived barriers to insulin delivery.
Results
Short-acting insulins, which should be administered 30 minutes prior to meals, were consistently
administered at incorrect times. Concerns of hypoglycemia and unpredictable meal delivery
times were key nursing-identified barriers to insulin administration, which were discordant
from findings observed.
Conclusions
Environmental and system factors on the inpatient medical units contribute to delayed
administration of prandial short-acting insulin.
Canadian Journal of General Internal Medicine
36 Volume 14, Issue 3, 2019
Original Research
RESUME
Contexte général
L’hyperglycémie chez les patients hospitalisés est associée à de multiples effets indésirables. Le
manque de coordination entre l’heure des repas et ladministration d’insuline peut aggraver le
contrôle glycémique. Les défis logistiques au niveau des systèmes qui influent sur le moment
de ladministration de l’insuline nont pas été examinés.
Problème local
Des recherches antérieures ont identifié des difficultés à coordonner l’administration d’insuline
prandiale avec les repas comme un obstacle à l’euglycémie à lhôpital.
Viser
Caractériser le processus dadministration d’insuline prandiale pour identifier les lacunes dans
les soins.
Méthodes
La cartographie des processus a été utilisée pour décrire ladministration d’insuline prandiale
dans une unité médicale pour patients hospitalisés. Les infirmières ont été interrogées afin
d’identifier les obstacles perçus à ladministration de l’insuline.
Résultats
Les insulines à courte durée daction, qui devraient être administrées 30 minutes avant les repas,
ont été administrées de façon constante au mauvais moment. Les préoccupations relatives à
lhypoglycémie et aux délais imprévisibles de livraison des repas étaient les principaux obstacles
à ladministration de l’insuline identifiés par les infirmières, qui étaient en désaccord avec les
résultats observés.
Conclusions
Des facteurs environnementaux et systémiques dans les unités médicales des patients hospitalisés
contribuent à retarder ladministration de l’insuline prandiale à action rapide.
Submitted: October 29, 2018. Accepted: June 3, 2019. Published: August X, 2019. DOI: 10.22374/
cjgim.v14i3.329
Diabetes affects one in five medical inpatients.
1,2
In-hospital
hyperglycemia is associated with adverse outcomes, including
increased mortality, infections, ICU admissions, length of hospital
stay, and healthcare costs.
3–5
Short-term hyperglycemia is also
impacts dehydration, electrolyte abnormalities, impaired wound
healing, prolonged illness and mortality.
3,5,6
The impact of strict
glycemic management on medical inpatients is under study; to
date, euglycemia has been associated with reduced infections.
7
To achieve euglycemia in non-critically ill inpatients, Diabetes
Canada recommends targeting a blood glucose level between 5.0
to 10.0 mmol/L through the use of basal bolus insulin therapy
(BBIT), a subcutaneous insulin regimen that consists of basal,
prandial and correction insulin.
8
Prandial insulin management in the inpatient setting may be
challenging; previous observational studies have demonstrated
that pre-meal glucose testing, meal delivery, and insulin
administration are not well synchronized in hospital.
9–11
This is
important as the two commonly used classes of prandial insulin
have different pharmacokinetics. In brief, “rapid-acting” insulin
analogs, such as lispro (Humalog), glulisine (Apirdra), and aspart
(NovoRapid), have an onset of action within 10 to 15 minutes of
administration and peak between 60 to 90 minutes after dosing.
8
Thus, rapid-acting insulins are generally delivered with the first
bites of a meal. In comparison, “short-acting” insulin analogs
such as Humulin R and Novolin Toronto have a later onset of
action, 30 minutes after administration, and peak 2 to 3 hours
later. These insulins are to be administered approximately 30
minutes prior to mealtime to match carbohydrate loads.
8
Improper
coordination between insulin pharmacokinetics and meal
consumption has been demonstrated to have adverse impacts
Canadian Journal of General Internal Medicine
Volume 14, Issue 3, 2019 37
Shannon M. Ruzycki et al.
on glycemic control, with five-fold more hyperglycemia with
delayed insulin administration compared with administration
on schedule.
11
Recent work from our institution on barriers and facilitators
for the implementation of BBIT in demonstrated that nursing staff
identified the coordination of blood glucose testing and insulin
delivery with meals as a major barrier to diabetes management.
12,13
Thus, as a first step in addressing these barriers, the objective of
this quality improvement study was to examine the practice of
inpatient prandial insulin delivery from the nursing perspective
to identify care gaps affecting the optimal timing of prandial
insulin administration through process mapping.
Methods
We developed a process map depicting the steps and gaps
in prandial insulin administration on the inpatient internal
medicine unit. Process mapping is a quality improvement tool
that uses visual illustrations to represent the steps, events, and
operations that constitute a complete process.
14
Process mapping
is commonly used to describe interdisciplinary processes with
multiple, complicated steps performed by a variety of healthcare
professionals.
14
Once established, a process map can identify
variation in delivery of care, care gaps, redundancies, and areas
for improvement.
14
Given that inpatient prandial insulin delivery
is a complex process involving coordination of multiple steps and
interdisciplinary roles, process mapping is a pragmatic method
to comprehensively describe this complex practice.
To create the process map, two team members (KL and SR)
directly observed nine registered nurses on an acute inpatient medicine
unit over a two-day period which included three meals. First, the
unit charge nurse identified bedside nurses caring for patients who
required prandial insulin. Second, these nurses were approached
by a study team member (KL or SR) and invited to participate.
Eligible nurses were informed that the goal of the observation was
to identify the steps in prandial insulin administration as part of a
quality improvement initiative. Third, among participating nurses,
each step of prandial insulin administration was recorded by the
observer and annotated with a time, location, and other relevant
details. Insulin orders were reviewed for all participating nurses.
Fourth, to cover all interdisciplinary team members involved
in prandial insulin administration, we conducted open-ended
interviews with representatives from pharmacy and food services
to understand their roles in this process. Fifth, the arrival of meal
trays on the inpatient internal medicine unit was recorded by the
unit clerk for each meal.
Finally, to characterize care gaps in prandial insulin
administration identified by the process map, one-on-one
interviews were conducted with five nurses who did not participate
in the observation phase. Interview participants were recruited
using a snowball sampling technique.
15
Nurses were provided
with the process map and asked to comment on each step. Nurse
responses were transcribed in real time.
This project received approval from ARECCI (A pRoject
Ethics Community Consensus Initiative) through Alberta
Innovates prior to initiation as it was assessed as a low-risk
quality improvement project.
Results
The insulin delivery process map identified important variability
in the practice of prandial insulin administration (Figure 1).
Most notably, prandial insulin was often administered after the
patient had begun eating and occasionally after the meal was
completed, regardless of the type of insulin used. Further, there
were no observed differences in the timing of administration
of short-acting or rapid-acting insulins. Importantly, during
the observation period, there were no instances where prandial
short-acting insulin was administered 30 minutes prior to a meal
as specifically ordered by physicians.
Barriers to correct timing of short-acting insulin were
explored using narrative interviews with registered nurses from
the internal medicine inpatient unit. Transcription of common
nursing responses to the discrepancy in timing between physician
orders and real practice is provided in Table 1. The predominant
themes identified were nursing concerns of patient safety (i.e.,
hypoglycemia) and variability in meal delivery. All five nurses
uniformly described an inability to predict meal tray arrival as
a barrier to coordination of insulin delivery with meals. The
majority of nurses reported that it was “unsafe” to deliver any
formulation of insulin before a patient began eating his or her
meal due to the unpredictability of meal tray delivery or patient
factors that would preclude eating (e.g., nausea and vomiting),
thus putting the patient at risk for hypoglycemia. All nurses
interviewed were aware of the physician orders for different
timing of pre-meal insulin administration between short- and
rapid-acting insulins.
Assessment of meal tray delivery timing on the internal
medicine inpatient unit revealed that meal tray arrival was, in
fact, consistent over a two-week period. Breakfast was delivered
at a mean of 8:46 a.m. (standard deviation [SD] 5 minutes), lunch
at a mean of 12:46 p.m. (SD 7 minutes) and dinner at a mean of
17:56 p.m. (SD 8 minutes).
Discussion
Coordination of prandial insulin delivery with meals in hospital
is complex. Mismatches between insulin dosing and mealtimes
exposes patients to increased risk of hyperglycemia,
9–11,15
which
is associated with adverse outcomes.
3–5
Observation of prandial
insulin administration on our inpatient internal medicine unit
Canadian Journal of General Internal Medicine
38 Volume 14, Issue 3, 2019
Original Research
Table 1. Feedback from Registered Nurses Regarding the Prandial Insulin Delivery Process Map
RN Comments
1 I measure blood sugar when I take vitals. No matter when the insulin is ordered, I don’t think it’s safe to give insulin before the meal trays arrive
because you never know when they will arrive. Also, your patient might be taken for a test during the mealtime. And they’re sick, so they might
vomit, or decide not to eat, or only eat half of their meals.
2 As soon as I hear the trays arrive on the unit, I take their blood sugar, and calculate the insulin ordered. Then once the tray is in front of them and
they’re planning on eating, I give the insulin. It doesn’t matter how the insulin is ordered because you can’t predict the meal trays.
3 It’s not safe to give insulin before you know that the patient is actually going to be able to eat on time. None of us do it, no matter what the
order says. If the patient doesn’t eat or the meal is late, you’ll be checking the sugar all day and giving juice.
4 I understand the different types of insulin and the orders and everything, but when we are on the unit we are taught to wait until the patient is
eating to give insulin for safety.
5 No one on the unit gives insulin before the meal tray is here because it isn’t safe. It’s dangerous to give a bunch of insulin and then wait for an
hour for the food.
Figure 1. Process map of prandial insulin delivery on the internal medicine inpatient unit.
Actions = squares; Diamonds = decisions; POCT = Point of care glucose testing; SCM = Sunrise Clinical Manager (electronic medical record).
Canadian Journal of General Internal Medicine
Volume 14, Issue 3, 2019 39
Shannon M. Ruzycki et al.