A Nurse Managed Computerized Program For Continuous IV Insulin Infusion:JIIP(Jefferson Insulin Infusion Protocol) and Non JIIP.

Joan Moshang RN BSN MEd. CDE

CIII Program Content Indications for JIIP and NON-JIIP

Physician,Nurse and Pharmacy responsibilities.

Practice Pathway for Titrating JIIP.

Requirements: RN will review the PowerPoint

presentation. RN will practice titration guidelines

on practice pathway on computer. RN will complete program quiz with

a grade of 100%. Unit CNS will review quiz results with

staff member.

Introduction

Uncontrolled hyperglycemia in hospitalized patients results in poor clinical outcomes.

IV insulin is the drug of choice for optimal glycemic management in many patients.

Safe administration of IV insulin is a complex task.

The Jefferson Hospital Insulin Infusion Protocol(JIIP) applies to all adult patients requiring IV insulin but ONLY if the JIIP is ordered.

General Guidelines Physicians who do not order the JIIP but

want continuous IV insulin infusion (NON-JIIP) for their patients, are responsible for the hourly titration of the infusion and specific fluid orders.

The RN may titrate a non –JIIP infusion

based on previous infusion guidelines online but only if the glucose and piggyback protocol is followed.

SO…. JIIP is a Jefferson Hospital nurse managed

protocol for delivering continuous IV insulin.

Non JIIP Continuous IV insulin infusion orders are titrated hourly by the ordering physician and must comply with the glucose and piggyback guidelines.

RN may not hang an insulin infusion that is

not piggybacked into another IV.

JIIP Candidates

ICU patients with BG>180mg/dl x 2 consecutive measurements.

NOTE: Check Blood glucose (BG) on admission to ICU and q4 hours thereafter. If BG <140mg/dl for first 24 hours, measure BG daily or as clinically indicated.

JIIP CandidatesAll other patients with BG >250mg/dl x 2 consecutive readings after initial oral diabetes medications or insulin therapy have failed.

All DKA (Diabetic Ketoacidosis) or /HHS (Hyperosmolar Hyperglycemic State)-See separate guidelines for management of DKA and HHS.

JIIP Candidates Type 1 DM requiring surgery/general anesthesia.

Type 2 DM with uncontrolled hyperglycemia or insulin requiring type 2 DM needing surgery/general anesthesia.

Note: It is best to start an IV insulin infusion the night before surgery. (Suggest Endo Consult for insulin orders.)

Never discontinue insulin on patients with type 1 diabetes. If BG 70 or less,follow hypoglycemia protocol and restart insulin when BG normal.

More Pearls

Once the JIIP protocol is initiated, all other insulin orders are discontinued, including CDI(Correction Dose Insulin) and insulin in TPN bag.

TJU Blood Glucose (BG) goals: 140-180mg/dl while on infusion 70-140mg/dl while off infusion

Blood glucose may NOT be decreased by more than 100mg/dl/hr.

PRECAUTIONS/WARNING

Patients with liver failure ,s/p liver transplant or ESRD(End stage renal disease) may need to be excluded from the protocol. Consult Attending physician.

On general and intermediate care floors,if insulin rates > 10 units/hour, notify House staff or Attending to determine if protocol should continue.

In ICU,insulin rates > 20units/hour must be OK’d by Attending physician. Endocrine service may be consulted in these

circumstances.

IV Fluid Guidelines

ALL patients with Blood glucose (BG)<250mg/dl must receive a minimum of 5gm of glucose/hour as:

D5/W, D5/NSS or D5/1/2NSS @100cc/hr. or a D10 solution at 50cc/hr.

CAUTION: post cardiac surgery DM patients on epinephrine should NOT receive D10 at greater than 25cc’s/hr.

Infuse D5 @50cc/hr.or D10@ 25cc/hr.)

Patients with BG <250mg/dl NOT receiving a source of dextrose/glucose cannot be on the JIIP.

Attending physician must be notified for further instruction.

RULE OF THUMB

Rationale The inclusion of D5/W piggyback solution

is a safety factor designed to avoid hypoglycemic events.

All Continuous Intravenous Insulin

Infusions (CIII )MUST be piggybacked into another IV solution.

Normal saline or D5/W at a “Keep open” rate is acceptable only if the patient is receiving tube feedings providing a mini-mum of 120 grams carbohydrates/day.

Key Points

Continuous IV insulin infusions (CIII) are either JIIP or NON-JIIP.

Infusion rates >than 10units/hr on general floors and >20 units/hr in ICU’s must be OK’d by physician.

Insulin infusions MUST be piggybacked into another appropriate solution.

Physician Responsibilities

Physician enters order for JIIP and orders the bolus dose and the initial infusion rate as follows:

Non DKA/HHS ex: (Pre-surgery, uncontrolled hyperglycemia,NPO post surgery etc.)

Divide initial BG by 100 and round to nearest 0.1unit.

(Ex: Current BG 200 divided by 100=2 units bolus and 2 units/hr.)

Physician Responsibilities

DKA/HHS

Calculate dose as 0.1units/kg (Ex: Weight in Kg.= 50 Kg x 0.1=5 Units

bolus and 5units/hr.)

Note difference between bolus and initial start rate of DKA/HHS AND NON DKA/HHS.

DKA/HHS(HHNK) In addition to ordering the different bolus

and initial infusion start rates for DKA/HHS, the physician must refer to DKA/HHS guidelines for BOH(Beta hydroxybuterate),anion gap,Potassium and fluid guidelines.

Once the bolus and initial infusion rates are administered,both DKA and NON-DKA are titrated by the RN according to the JIIP table.

DKA/HHS cont. Patients in DKA on JIIP or Non JIIP with

ketones present must remain on the infusion until their ketones are normalized, even if the BG is normal.Check the BOH(beta hydroxybuterate) and/or anion gap and the DKA guidelines.

(Must maintain insulin rate at minimum of 0.02 units/kg/hr. Ex:70kg pt.x0.02=1.4units/hr.)in patients with DKA/HHS

For DKA/HHS Drip Titration:

a.If Insulin Rate calculation less than 0.02 unit/kg/hr there is a pop up warning stating:

The calculated rate is less than 0.02 unit/kg/hr and a potentially suboptimal low insulin

infusion rate. Please call physician to determine the appropriate amount of Dextrose IV.

a.If BG less than 250, there is a pop up stating:Recommend IV fluids D5 at 150- 250 cc/hr 

DKA/HHS(HHNK) Patients in DKA with a normal or near

normal BG …but still spilling ketones…will require a higher hourly rate of

glucose to allow for continued insulin administration. Call physician for order change.

Rationale The Blood glucose is usually corrected

before the ketones are cleared. Premature discontinuation of the insulin infusion will cause a rebound effect.

Caution!

Note: although the physician is responsible for entering the correct order set, the RN must recognize the difference between DKA and non-DKA management guidelines for safe patient care.

When communicating with the physician,always state if patient has

type 1 or type 2 DM.

FYI: Physician Order Sets Include “pop ups” for DKA/HHS

management including Potassium and fluid guidelines.

Multiple “pop up” reminders for monitoring, transition to subcutaneous insulin etc.

Pharmacy’s Responsibility Pharmacy prepares and labels the

infusion:100 Units regular insulin in 100cc’s NSS.

Pharmacy prepares and labels the bolus dose ordered by physician:

-If not DKA/HHS, Initial BG divided by 100 and rounded to nearest 0.1unit. -If DKA/HHS, 0.1unit/kg.

Nursing’s Responsibilities 2 RN’s view the order and verify the

label and rate changes. RN flushes IV line with 20cc of infusion

to saturate insulin binding sites in tubing.

2 RNs administer the IV bolus and initiate the infusion at rate ordered by physician.

2 RNs titrates infusion as determined by calculations on insulin table.

No protocol trumps clinical decision making.

The RN must be vigilant in: --assessing patient for nutritional changes,

-meds which can increase or decrease BG values, fever ,etc.

-Reason for infusion- DKA,Surgery,uncontrolled hyperglycemia?(the bolus and start rate depend on the reason why the infusion was initiated).

Insulin Rate Adjustment table

You must use the computer table to calculate rate changes.

A practice pathway will be available on each unit.

The table addresses rate change only.

For safe patient management,you must be aware of changes such as NPO status, steroid induction, clogged feeding tubes etc.

IN A NUTSHELL: Physician places order. Pharmacy prepares fluids and bolus

dose. 2 RN’s check order which includes

bolus and initial infusion rate. RN administers bolus and starts

infusion and enters current BG.

RN

Rechecks BG in one hour,enters current BG on MAR and based on current and previous BG results:

clicks on insulin rate tab (Bottom left of screen) and titrates according to the rate calculated by titration table.

HOW’d THEY DO THIS?? Endocrine reviewed multiple adjustment

guidelines .

Inserted multiple case scenarios and developed titration table.

Following are examples of how the titration units were determined..

(For information only):You will not see this on the viewer)

Current BG

≤ 70 71-99 100-140 (120)

141-180 181-240(210)

241-300

∆ in BGDec by >101

STOP‡ Stop* Stop# Stop# Stop# Stop#

Dec by 50 - 100 STOP‡ Stop* Stop# Stop Dec by 50%

Dec.by 25%

Dec by 25 - 49 STOP‡ Stop* Stop# Dec. by 25%

No change

No change

Dec or Inc by 0 - 24

STOP‡ Dec by 50%

Dec. by 25%

No change

Inc by 25%

Inc. by 50%

Inc by 25 - 49

STOP‡ No change

No Change

Inc by 25%

Inc by 25%

Inc. by 50%

Inc by ≥ 50 STOP‡ No change

Inc by 25%

Inc by 25%

Inc by 50%

Inc.by 100%

# Stop Infusion for 15 minutes. Restart @50% of previous rate. Make sure D/5 or D/10 is added.

Current BG

≤ 70(65)

71-99 100-140 141-180(150)

181-240 241-300

∆ in BGDec by >101

STOP‡ Stop* Stop# Stop# Stop# Stop#

Dec by 50 - 100 STOP‡ Stop* Stop# Stop Dec by 50%

Dec.by 25%

Dec by 25 - 49 STOP‡ Stop* Stop# Dec. by 25%

No change

No change

Dec or Inc by 0 - 24

STOP‡ Dec by 50%

Dec. by 25%

No change

Inc by 25%

Inc. by 50%

Inc by 25 - 49

STOP‡ No change

No Change Inc by 25%

Inc by 25%

Inc. by 50%

Inc by ≥ 50 STOP‡ No change

Inc by 25%

Inc by 25%

Inc by 50%

Inc.by 100%

ALL BG’S<THAN 70mg/DL.

STOP INFUSION:Obtain lab serum glucose and document symptoms on hypoglycemia schemata.

For BG 40-70mg/ dl: Able to take oral: give 15 grams of oral glucose. Unable to take orals :1mg glucagon SC/IM or

I f altered consciousness,give ½ amp D50 (12.5gm)

Recheck BG q 15minutes until BG >100mg/dl and restart infusion at 50% of previous rate.

Ensure D5 or D10 is added for BG<250mg/dl.

ALL BG’S<THAN 70mg/DL. STOP INFUSION:Obtain lab serum glucose

and document symptoms on hypoglycemia schemata.

For BG 40-70mg/dl: Able to take oral: give 15 grams of oral glucose. Unable to take orals :1mg glucagon SC/IM or If altered consciousness,give ½ amp D50

(12.5gm) Recheck BG q 15minutes until BG >100mg/dl

and restart infusion at 50% of previous rate. Ensure D5 or D10 is added for BG<250mg/dl.

Blood glucose <40mg/dl

Serum specimen to lab. 15Gm of oral glucose if able to take. If altered consciousness:1/2 amp D50 IV. If no IV access,give 1mg glucagon SC or

IM. Recheck BG q 15 minutes until BG > 100mg/dl. Restart infusion @50% of previous rate.

Key Points The bolus dose and insulin start

rates depend on the reason for the infusion.

There must be a constant source of glucose during insulin infusions.

2 RN’s must verify rate changes. Hypoglycemia and critical value

protocols must be followed.

Monitoring

BG monitoring is done q 1hour until BG 140-180mg/dl for 2 consecutive hours;then q2hours if no significant change in status.

Return to q 1hour monitoring if: - Starting or stopping steroid therapy. -Starting or stopping dialysis. -Starting, stopping or rate change of

tube feedings or hyperalimentation. -Infusion rate change.

Glucose Interruptions If BG < than 250mg/dl and glucose

containing fluids are interrupted for some reason, stop insulin infusion.

Check BG q 15 minutes until glucose source restarted.

Restart insulin infusion.

Clinical Situations

Continuous Tube Feedings -If receiving 120 gms of carbohydrate in 24

hours,may maintain D5W @40cc’s/hr.

Stopping tube feedings. -To continue JIIP, must have glucose source

@100ml/hr.

Interruptions in insulin delivery.-

Patient Transfers Patients on JIIP who are transferred from

OR, ER etc. to a general unit:

Check BG immediately and again in 15 minutes.

Based on the 2 values,titration rates are

made according to the protocol.

Review section on Monitoring.

Transition To Subcutaneous Insulin

Do NOT D/C the infusion for patients with Type 1 DM who are spilling ketones even if BG is normal.

Never stop infusions during the night:pre-breakfast or pre-dinner is optimal.

If ketones are controlled and BG is 180mg/dl or less, transition to sc insulin is appropriate.

When Transitioning To Subcutaneous Insulin:

Start subcutaneous Insulin PRIOR to the discontinuation of insulin drip based on type of insulin given. The best times for transition are PRIOR to breakfast or dinner. RECOMMENDED OVERLAP TIMESLispro or 75/25 15 minutesRegular or 70/30 30 minutes – 45 minutesNPH 2 hoursLantus or Levemir 2-3 hours  

Computer downtime Click on clinician on Intranet.

Under clinical applications,scroll down to:

Insulin calculator for Jeff chart downtime. Note: Actual calculator will be updated to reflect

use on all care units-not only Intensive care units.

Proceed to quiz if you are able to:

State the rationale and indications for continuous insulin infusions.

State the bolus and insulin start rate for DKA/HHS vs. Non-DKA/HHS. Utilize titration table correctly. Manage hypoglycemic events per protocol. State transition times from insulin infusion

to subcutaneous insulin based on type of insulin ordered.

Must answer all questions correctly:Circle correct answer.

1.Physicians may order the JIIP without piggybacking the infusion into a main line. True False

2.The titration table is the same for both DKA/HHS and non DKA/HHS patients. True False

3.Two RN’s must verify all rate changes. True False

4.In the event of a clogged or dislodged feeding tube,it is important to maintain a steady rate of insulin.

True False

5.The blood glucose is often corrected before the blood ketones. Therefore, maintain the insulin infusion in type 1 diabetics until ketones are normalized even if the BG is normal.

True False

Quiz continued:

6.The critical value protocol is the same whether on or off the insulin infusion. True False

7.Blood glucose test results must be entered into the computer within

10-15minutes. True False

8.Insulin rate changes are based on the current blood glucose result. True False

9.Stop the infusion if BG <than 70mg/dl;restart @ 50% of rate when BG is 100mg/dl. True False

10.Maintaining a normal BG and preventing hypoglycemia are the main goals of continuous IV insulin therapy.

True False

Unit CNS Responsibilities: Unit clinical nurse specialist will assume

responsibility for staff competence in utilizing protocol.

Will supervise staff proficiency with practice pathway. Maintain records to reflect: -Completion of Nurse Managed JIIP power point and quiz with grade of 100%. - Proficiency in use of training pathway.