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1. Unit - 9 West Pavilion Michael Bredefeld RN BSN, Cecilia Wanjiru RN BSN, Victoria Sifrovich RN ASN Yale-New Haven Hospitals York Street campus and associated ambulatory sites are Magnet-designated by the ANCC.

2. Does increased communication between dietary staff, RNs, PCAs and patients improve blood glucose management? P - Inpatient diabetic patients excluding those NPO or on enteral/parenteral feedings. I Improve communication between dietary, RN, PCA and patient by education and implementing signage. C No intervention O Improve blood glucose control by reducing the time between meal tray arrival and insulin administration. Yale-New Haven Hospitals York Street campus and associated ambulatory sites are Magnet-designated by the ANCC.

3. Understand the articles pertaining to effective blood glucose management in diabetic inpatient populations Acknowledge the relevance of Blood Glucose Level (BGL) control, meal delivery and insulin administration coordination Understand that an increase in communication between dietary staff, RNs, PCAs and patients pertaining to blood glucose management is necessary.

4. More than 24 million people in the U.S. have diabetes. Potential of increased hospital stay for diabetic patients. Nurses have a significant role in managing patients with diabetes. It is necessary that a patients meal intake, insulin administration, and glucose monitoring be tightly coordinated.

5. Suggestions by Institute for Clinical System Improvement for the management of type 2 DM: 1) Regular insulin administration - at least 30 minutes before a meal 2) Rapid acting insulin administration - within 30 minutes of capillary blood glucose testing and 10 to 15 minutes of meal consumption. Institute for Clinical System Improvement (2012).

6. Relationship of Glucose Values To Sliding Scale Insulin (Correctional Insulin) Dose Delivery and Meal Time In Acute Care Patients With Diabetes Mellitus. Barbara Trotter, Mark R. Conaway and Susan Burns (2013) Medsurg Nursing Purpose: To determine the effect of timing intervals on BG values and insulin dosing Level of Evidence 3 Sample (N=60 adult pts) Findings: BGL measurements were statistically significantly lower with increased time between PCA and RN measurements P= am 0.002, pm 0.007 BGL was significantly lower with increased time by 20.6 points.

7. Timing is everything. Lampe et al. (2014).Clinical Nurse Specialist Journal Level of Evidence 3 Purpose: Evaluate the timing and practice of blood glucose testing and rapid acting insulin administration around meal times Method: Direct observation of the timing of RAI administration, timing of BG testing and food intake Findings: Overall only 14% of BGLs were tested within 1 hour prior to insulin administration

8. Timing of Insulin Administration and Glucose Monitoring in the Hospital. Barbara Freeland, Barbara Penprase and Maureen Anthony(2011). The Diabetes Educator Level of evidence: 3 Purpose: Examine if Nursing care met rec. standard Sample: A nonrandom convenience sample (N=50) Methods: Observations were made on BGL monitoring, meal intake and insulin administration times. Findings: Only 8 patient (16%) fell within the standard (within 10 minutes of meal). The mean insulin administration time was 21.4 minutes.

9. Obtained permission from corporate compliance to access patient medical records Developed a form for nurses to record meal arrival. EMR was reviewed for BGL time and insulin administration time Designed and Implemented communication sign to be placed on pt door and in pt room

10. Please press call button when giving patient meal tray. Thank you.

11. Please press call button when your meal tray arrives. Thank you.

12. Educate RNs, PCAs, BAs and dietary staff regarding use of signage. Utilize signage, Educated patient to use call light when meal tray arrives Educate dietary to press call button when tray delivered Educated BA to notify RN when meal arrived Educated RNs to record meal time delivery

13. Data collected on: Time of blood glucose monitoring Meal delivery time Correctional insulin administration time Signage and education to RNs, PCAs, dietary staff and patients then followed.

14. Baseline meal arrival sample size=60. Known meal time= 44/60 (73.3 %) Standard met =33/60 (55 %) In other words 73% of the nurses knew when the tray arrived but only 55% administered the s/s insulin within the recommended standard amount of time.

15. Sample size=54 Known mealtimes= 47/54 (87%) There was a 13.7% increase in known meal tray arrival time. Standard met =39/54 (72.3 %) Difference in % between pre and post demonstrates 17.3% improvement in the standard of care being met.

16. Use signage on units for meal delivery Inservice education for RNs, BAs, PCAs and Dietary staff concerning the need for tighter timing of insulin administration and meal tray arrival. Reinforce with patients the importance of calling when meal tray arrives Continue monitoring BGL, meal tray timing and insulin administration for opportunities to improve outcomes.

17. Trotter B., Conaway M. and Burns S. (2013). Relationship of Glucose Values To Sliding Scale Insulin (Correctional Insulin) Dose Delivery and Meal Time In Acute Care Patients With Diabetes Mellitus. Medsurg Nursing, 22, 99-104. Freeland B., Penprase B., Anthony M. (2011). Nursing Practice Patterns: Timing of Insulin Administration and Glucosse Monitoring in the Hospital. The Diabetes Educator, 37, 357-362.

18. Lampe J., Penoyer D.A., Hadesty S., Bean A., Chamberlain L. (May/June 2014). Timing is Everything. Clinical Nurse Specialist Journal, 161- 166. Institute for Clinical System Improvement. (2012) Health care guideline: Diagnosis and management of type 2 diabetes mellitus in adults. www.icsi.org/guidelines__more/catalog_guidelines _and_more/catalog_guidelines/catalog_endocrine_ guidelines/diabetes.

19. Joan McNeil APRN Corporate Compliance Dietary staff Tywana Mitchell 9 west BA Jen Morrey APSM BSN RN Sharon Klein PSM RN MSN Yale New Haven RNs

20. More than 24 million people in the United States suffer from diabetes. Management of diabetes in the hospitalized patient require tight coordination between meal tray delivery, checking capillary blood glucose levels (BGL) and administration of rapid acting insulin. Studies have shown a link between hyperglycemia, diabetic complications and mortality rates. Patient complications and mortality rates increase with poor BG control. Patient satisfaction has been shown to be higher with greater BG control. The problem stems from the fact that mealtime is not fixed and each patient orders meal randomly based on eating habits. This lack of coordination causes patients to experience postprandial hyperglycemia resulting in an extended hospital length of stay. For optimal patient outcomes, it is imperative that tight glycemic control is achieved in the inpatient population. The purpose of this project is to develop a meal delivery protocol and communication tool for the inpatient diabetic patient. This tool and education, will improve communication between nursing, patients, and secretaries to better coordinate timely administration of rapid acting insulin to prevent postprandial hyperglycemia in the inpatient on the transplant unit. This project was conducted with the use of signage to increase communication between the dietary staff, RNs and patients. Signs were posted inside the patient room and on the doorway instructing the patient or dietary staff to press the call button when the meal tray arrives. If the RN was aware of the meal tray arrival and insulin was administered within 15 minutes, then the standard of care was met. If the nurse was not notified, or insulin was not administered within 15 minutes, then the standard was not met. Pre- and post- interventions were recorded and results were tabulated. Known tray arrival increased by 13.7%. The % difference between the standard being met pre and post was 17.3%. A Chi square analysis was performed on the proportions. The increase in communication resulted in a greater awareness of meal tray arrival to a statistically significant level (0.05).

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Documents

insulin administration

regular insulin administration

glucose monitoring

blood glucose control

patients meal intake

timing of rai administration

meal delivery

minutes of meal consumption