INPATIENT BLOOD
GLUCOSE CONTROL:
Policies, Procedures, and Protocols
A learning module for
UNIT SECRETARIES
at Saint Joseph Health System
Developed by: Dana Graves RN, MSN, CDE
Diabetes Clinical Nurse Specialist
December 2008 revised
INPATIENT BLOOD GLUCOSE
CONTROL: Policies, Procedures, and Protocols

1.
2.
This learning module is required for orientation to
Diabetes Care issues and blood glucose control here at
Saint Joseph Health System. This can also be used for
periodic reviews as needed.
The purpose of this module is:
To discuss the importance of blood glucose control in the
hospital.
To orient you to the policies, procedures, and protocols
used for inpatient blood glucose control.
At the end of this module,
you will take a 16 question post-test.
DIABETES RELATED
PREVALENCE DATA
WHY IS BLOOD GLUCOSE CONTROL SO IMPORTANT
IN THE HOSPITAL SETTING?
Diabetes prevalence data and research data
provide that answer.
 Diabetes has reached epidemic proportions in the U.S. affecting
more than 20 million people.
 More than 300,000 Kentuckians have diabetes.
 One in two Kentucky adults are at risk for developing diabetes.
 Diabetes is the 5th leading cause of death in Kentucky.
 Nationally, about 5,000 adults are diagnosed every workday.
 Diabetes is the leading cause of blindness, non-traumatic
amputations, and end-stage renal disease.
 With diabetes, the risk of heart disease and stroke is 2 to 4 times
higher than those without diabetes.
DIABETES RELATED
RESEARCH
RESEARCH SHOWS THAT BLOOD GLUCOSE
CONTROL IN THE HOSPITAL WILL HELP
DECREASE MORBIDITY AND MORTALITY RATES
For Example:
Hyperglycemia and:
Myocardial Infarction
Stroke
Cardiac Bypass
General Surgery
Can lead to:
Increased mortality risk
Greater disability risk for those admitted with
a blood glucose of >120mg/dl; and, Doubles
the mortality risk
Increased mortality rate and increased sternal
wound infections
Increased risk of serious infections (six times
the risk of serious infections)
DIABETES RELATED
RESEARCH
“Diabetes increases the risk for disorders that
predispose individuals to hospitalization,
including coronary artery, cerebrovascular and
peripheral vascular disease, nephropathy [kidney
disease], infection, and lower-extremity amputations.
Recent studies have focused attention to the
possibility that . . . aggressive treatment of
diabetes and hyperglycemia results in reduced
mortality and morbidity.”
Clement, S., Braithwaite, M., et al. Management of Diabetes and Hyperglycemia in
Hospitals. Diabetes Care, volume 27, number 2, February 2004, p. 553.
DIABETES RELATED
RESEARCH
Two landmark research studies (DCCT and UKPDS) showed that keeping
blood glucose levels close to normal slowed the onset and progression
of eye, kidney, and nerve diseases.
 The Diabetes Control and Complications Trial (DCCT) was a clinical
study that involved over 1400 people with Type 1 diabetes.
 DCCT Study findings included:
–
–
–
–
76% risk reduction in eye disease
50% risk reduction in kidney disease
60% risk reduction in nerve disease
35% risk reduction in cardiovascular disease
 The United Kingdom Prospective Diabetes Study (UKPDS) involved
over 5,000 people with Type 2 diabetes. It also showed similar risk
reductions.
DIABETES RELATED RESEARCH
If the DCCT and UKPDS data are so compelling,
why hasn’t it been applied to the hospital setting
before? Recommendations needed to be
published.
In 2003 and again in 2006, the American Diabetes
Association (ADA) and the American Association
of Clinical Endocrinologists (ACE), based on
clinical trial results, made recommendations for
the management of hyperglycemia in the
hospitalized patient.
DIABETES RELATED RESEARCH
Often times diabetes has been undiagnosed during
hospitalization and thus untreated. Now we have
data proving the importance of inpatient blood
glucose control and thus diagnosing diabetes
earlier.
Based on this data and more, Saint Joseph
Healthcare has made the commitment to inpatient
blood glucose control for ALL patients regardless
of diabetes diagnosis or not.
BLOOD GLUCOSE CONTROL
POLICIES, PROCEDURES, and PROTOCOLS
Current policies, procedures, protocols, and documentation forms
reflect the need for inpatient blood glucose control. They include:
Protocols and Standing Orders:
 Blood Glucose Control
Protocol
 Hypoglycemia Protocol(s)
 Perioperative Blood Glucose
Control Protocol
 Insulin Pump Standing Orders
 DKA Standing Orders
 Non Critical Care IV Insulin
Infusion Standing Orders
 Critical Care IV Insulin
Infusion Standing Orders
 SQ Insulin Standing Orders
Documentation Forms:
 Blood Glucose Section of the Patient
Care Flowsheet
 MAR
 Blood Glucose Hourly flowsheet
 Patient Discharge Instructions sheet
 Admission History (peach color sheet)
 Treatment Plan: Diabetes section
 Interdisciplinary Consult and Education
Record
Policies and Procedures include:
 Insulin Preparation and Administration
Procedure
 Use of Patient Owned Equipment
 Insulin (Pharmacy policy)
 Use of Blood Glucose Control
/Diabetes related protocols
BLOOD GLUCOSE CONTROL
POLICIES, PROCEDURES, and PROTOCOLS
For the purpose of this orientation module for Unit Secretaries, only those
forms and procedures that are appropriate to your role will be
discussed.
The protocols and standing orders are located in the Endocrinology
section of the Orders and Forms section of the SJH Intranet.
All Protocols and Standing Orders are to be placed in the
Orders section of the patient’s chart.
Key Points
As you now know, blood glucose control is the KEY to
decreasing morbidity and mortality rates.
(Key Points are special little reminders of importance!)
BLOOD GLUCOSE CONTROL
POLICIES, PROCEDURES, and PROTOCOLS
So, let’s begin with looking just at the
protocols and standing orders! We will
begin with the Blood Glucose Control
Protocol which was developed in January
2007 and revised in December 2008.
It reflects the need to focus on blood glucose
control for ALL patients, even those who
may not have a diabetes diagnosis but have
inpatient blood glucose control issues.
BLOOD GLUCOSE
CONTROL PROTOCOL
Key Point:
This protocol is to be used for all
patients who have been
admitted for diabetes and any
patient with a blood glucose
of 150mg/dl or greater,
regardless of diabetes
diagnosis or not.
Also, please note that it is NOT to
be used on OB patients or 23
hour admits or those patients
who are admitted with DKA
or HHS (hyperglycemic
crises)
(This is noted in the top left corner of
the protocol)
BLOOD GLUCOSE
CONTROL PROTOCOL
ALL THE ORDERS on this form are AUTOMATIC orders
 That means you will need to take all of them off !
 It is especially important to make sure the A1C and the CMP are ordered!!!
 Note that there are some lines provided to write down the order number
 Some orders do not require an order number, make sure all orders are transferred to
the appropriate form
Consistent Carbohydrate diet is the type of diet for people with diabetes; ADA is not the
correct term. 1800 calories is the default unless ordered differently on the order sheet.
 However, currently the STAR system still lists the diets as ADA or diabetes diet
 Consistent Carbohydrate diet means that the amount of carbohydrates the patient
eats will be balanced throughout all the meals and snack for a 24 hour period.
FSBG is finger stick blood glucose; frequency is to be AC & HS unless NPO, (0300 x2
days) etc. or if physician writes a separate order (see order #8).
All the other orders listed refer to placing other protocols or standing orders on the
chart if appropriate.
BLOOD GLUCOSE CONTROL
PROTOCOL
KEY POINT:
Do NOT automatically consult DNC or DTY unless the
doctor writes a separate MD order, OR the nurse tells
you to put in a Nursing Referral.
Also remember, that an order written for Diabetes Diet
instruction does NOT go to the Diabetes & Nutrition
Center (DNC), but INSTEAD it goes to Dietary
Miscellaneous (DTM) as diet instructions for the dietitian
to teach the patient.
BLOOD GLUCOSE CONTROL
PROTOCOL
OK! That is the Blood Glucose Control Protocol.
Even though the Blood Glucose Control protocol is
to be initiated on ALL patients with diabetes or
those patients with FSBG >150mg/dl, this
protocol still requires a doctor’s signature.
So, remember to place a RED “sign here” flag on
it.
Key Point:
Implementing this protocol should become fairly
automatic and routine for you!
HYPOGLYCEMIA PROTOCOL
There are actually 3 different
hypoglycemia protocols:
– Hypoglycemia Non-pregnant Adult over 100lbs.
– Hypoglycemia Pregnant Protocol
– Hypoglycemia Children under 12 years and Adults less
than 100lbs.
Again, these protocols are located in the
SJHS Intranet in the Orders section
under Endocrinology.
HYPOGLYCEMIA PROTOCOL
Key Point:
The Hypoglycemia protocol does
not need a physician’s order to
implement it. However,
eventually a signature will be
needed. So remember to place
a RED “sign here” flag on it.
The nurse may ask you to print this
when needed. It is located in
the Orders & Forms section of
the SJHS Intranet.
HYPOGLYCEMIA PROTOCOL
There is also a
“Hypoglycemia Protocol
MAR”. This is an MAR
that prints automatically
with the “Blood Glucose
Control Protocol”.
This MAR is to be placed
behind the current MAR
so the nurse has it to use if
and when a patient
experiences
hypoglycemia.
HYPOGLYCEMIA PROTOCOL
One last thing regarding Hypoglycemia . . .
What would you do if the patient calls out on the
intercom and says he is sweaty, feeling light
headed, dizzy, shaky, and / or weak feeling?
These may be signs of hypoglycemia. You would
need to contact the nurse right away and let her /
him know of these symptoms.
The nurse must treat hypoglycemia immediately!
HYPERGLYCEMIC CRISES
STANDING ORDERS
The DKA (Hyperglycemic Crises)
standing orders are to
be implemented on all
patients who are
admitted with DKA
(Diabetic Ketoacidosis) or
HHS (Hyperglycemic
Hyperosmolar Syndrome).
HYPERGLYCEMIC CRISES
STANDING ORDERS
When a patient is admitted with DKA or
HHS, the physician should be reminded of
the availability of this order set and the
form placed in the chart.
A RED ‘sign here’ flag should be placed on it
indicating the need for the doctor’s
signature.
IV INSULIN INFUSION
STANDING ORDERS
There are 2 other insulin drip standing orders:
 The Non Critical Care IV Insulin Infusion standing
orders is for use on the Medical/Surgical and Telemetry
units.
 The Critical Care IV Insulin Infusion standing orders
is for use in the Critical Care Units ONLY.
Both require a physician’s signature in order to
implement them. So, once again, a RED ‘sign
here’ flag will be needed.
The Non Critical Care IV Insulin Infusion standing
orders may require some individualization by the
doctor.
BLOOD GLUCOSE HOURLY
FLOWSHEET
 The Blood Glucose Hourly Flowsheet is to
be used ONLY with the Non-Critical Care
IV Insulin Infusion standing orders.
 One copy will print automatically when the
IV insulin infusion standing orders is
printed.
 Remember to print at least 3 more copies
and give them to the nurse for his/her use.
INSULIN PUMP STANDING
ORDERS
The next protocol is the
Insulin Pump
standing order set
which is to be used on
all admitted patients
who have an insulin
pump.
EXTERNAL INSULIN PUMP
INPATIENT ORDERS
When a patient is admitted:
Place this form on the chart
Then place a red ‘sign here’ flag on the form
(indicating physician signature is needed)
Lastly, but most importantly, place a Diabetes
& Nutrition Center (DNC) referral (this is to be
done automatically on ALL patients who have
an insulin pump) (write insulin pump in the
comments section)
PERIOPERATIVE BLOOD
GLUCOSE CONTROL PROTOCOL
The next protocol is the Perioperative
Blood Glucose Control Protocol.
This protocol primarily has orders related to
FSBG monitoring and what to do with the
pre-operative and post-operative diabetes
medication orders.
Insulin orders may need to be specified by the
physician.
PERIOPERATIVE BLOOD
GLUCOSE CONTROL PROTOCOL
A red ‘sign here’ flag is to be placed on
the form indicating physician signature
is needed.
Key Point:
This protocol is to be used only on those
admitted surgical patients with diabetes
who will come through the Outpatient
Surgery Department and PACU.
STAR ORDERING
One last reminder about orders . . . . . . .
When placing an order for the Diabetes & Nutrition
Center, there are 2 line items in the DNC ordering
screen. These are:
MD Consult for teaching
 This means that the doctor has actually written the
order for DNC to come see the patient.
Nursing Referral for assessment
 This means that the Nurse wants DNC to come and
assess and/or teach the patient.
Please make sure you select the appropriate order.
This helps DNC to prioritize their work load!
BLOOD GLUCOSE CONTROL
POLICIES, PROCEDURES, and PROTOCOLS
That ends the section on Protocols and Standing
orders.
The next section will cover the documentation forms
that are used for documenting diabetes care and
blood glucose control issues. The first sheet to
look at is the Patient Care Flowsheet.
As the Unit Secretary, you will be responsible for
making sure the Patient Care Flowsheet is
available. This is the 24-hour ‘nursing notes’ for
the nurses to document on.
ADMISSION HISTORY
(PEACH COLOR SHEET)
The next form, the Admission History sheet (peach color
sheet) has an Endocrine section located at the
bottom of the first page.
In this Endocrine section, the nurse might assess the
need for a referral to the Diabetes & Nutrition
Center (DNC) or Dietary (DTM). So, the nurse
may ask you to place a Nursing Referral to either
department.
Keep in mind that those are actually 2 separate
orders to 2 different hospital departments (DNC
and DTY).
PATIENT DISCHARGE
SUMMARY SHEET
The next form, the Patient Discharge
Summary sheet, has several places on
which to document information related to
diabetes.
This form is used by the nurse at discharge.
It is a duplicate form in which one copy will
be given to the patient at discharge and one
copy stays on the chart.
TREATMENT PLAN
The Treatment Plan (kardex) is printed on a hard
paper stock and is used by the nurses to help give
report!
When you take off orders, you may have to add
some orders to this form.
There is a Diabetes section to document type of
diabetes and FSBG frequency.
The back of the Treatment Plan has a lined section
that can be used for reminders for diabetes care /
blood glucose control issues such as teaching
needs, teaching done, insulin pump rates and set
changes, etc.
INTERDISCIPLINARY CONSULT
AND EDUCATION RECORD
The Interdisciplinary Consult and Education
record (Care Plan and Caremap) is used to
document all initial and ongoing teaching
done by the nurse and even other
departments.
This form is actually the front page of the
CareMap.
The nurse may carry this with her/him on their
clipboard.
CAREMAP
Each CareMap has a section for daily assessment of
Hyperglycemia and Hypoglycemia and whether
target blood glucose goals are met or not met.
The inpatient target blood glucose ranges, listed on
each CareMap, are:
Med/Surg/Telemetry is 70 – 180mg/dl
Critical Care is 80-110mg/dl
MEDICATION ADMINISTRATION
RECORD (MAR)
The last form, the MAR, is one you may be
familiar with by now.
All oral diabetes medications, basal insulin,
bolus insulin, correction insulin, insulin
pump rates, and IV insulin drips must be
documented on the MAR.
All medication doses, time given, and who
gave it are documented on the MAR.
MEDICATION ADMINISTRATION
RECORD (MAR)
As the Unit Secretary, you will be responsible for
adding all new medication orders to the MAR.
It is important to remember to document the date of
the order, the drug name, dose, and frequency.
One more reminder, Correction Insulin (the weight
based scale) may be pre-printed on stickers,
making it easier for you to choose the right weight
based scale and then place it on the MAR.
POLICIES & PROCEDURES
There are several different policies and
procedures related to diabetes and blood
glucose control. These include:




Insulin Preparation and Administration Procedure
Use of Patient-owned Mechanical Equipment while Hospitalized
Use of Blood Glucose Control /Diabetes related protocols
Insulin (Pharmacy policy)
Since the Insulin Preparation and Administration Procedure
is for nurses only, we won’t be discussing it. So, let’s
briefly look at the others.
POLICIES & PROCEDURES
Use of patient owned mechanical equipment while
hospitalized policy states
 Since the hospital cannot assure that equipment brought from
home is in good working order and that staff may not be familiar
with it, home equipment is generally NOT permitted in the
hospital.
 Any mechanical equipment brought in by the patient and/or family
should be sent home with the family.
 Non-electric equipment (ie, wheelchairs, canes, walkers) can be
used in the hospital. All such equipment must be clearly marked
with the patient’s name. Patient and family members retain all
responsibility for any such item.
 Insulin pumps, however, are an exception and can be used in
accordance to the ‘External Insulin Pump’ standing orders.
POLICIES & PROCEDURES
The “Use of Blood Glucose Control /
Diabetes related protocols” policy
discusses the use of all the protocols and
standing orders.
This Nursing policy is a good reference for
when you have questions regarding any of
the diabetes or blood glucose related
protocols or standing orders.
PHARMACY SERVICES
POLICIES
The last policy to discuss “Insulin, Human” (064-IDD-38C) is
actually a pharmacy policy that lists the insulin substitutes.
SJHC’s formulary mainly has Novolin insulin products
(Regular, Lente, NPH, 70/30)
Why do you need to know this policy? Because a physician
may write an order to substitute the Novolin brand insulin
for a different one. And that’s OK.
However, a “Do Not Substitute” order can be written by the
doctor and it is to be followed as it is written. After you
FAX the order, Pharmacy will then make sure that
Substitution is correctly made.
RESOURCES
In the Saint Joseph Health System home page,
there’s a Department tab. If you click on this you
can go into many different hospital departments.
If you select the Diabetes & Nutrition Center tab,
you will see that it has Nursing Diabetes
Newsletters, Diabetes Orders, forms and guides,
as well as Diabetes Resources (articles and
websites).
So, you have some Diabetes resources at your finger
tips!
THE FINISH LINE!!!
CONGRATULATIONS!
You have finished the
Blood Glucose Control:
Policies, Procedures, and Protocols
Learning Module
If you have any questions, please contact your Clinical
Educator, your unit’s Diabetes Champion,
or one of the Diabetes Educators.