Problem: who should do the accuchecks?

[UM Review RN, ASN, RN]

We've recently begun a new program in which patients can call their meals to the kitchen any time they want.

The concern is with diabetics and those who have pre-meal accucheck orders. Some of them don't know they have accucheck orders because it's part of our standing orders for stroke. Others know and are not compliant.

Worse (to me, anyhow), even if a patient is alert, oriented, and a longtime diabetic, they need take no responsibility for asking for their accucheck and their insulin before they eat.

The accuchecks used to be done on day shift. Now it's being shifted to nights.

Several problems we're encountering:

1. Our techs do the vitals and they already are quite overburdened. We're supposed to "help" the techs, who can have up to 20 patients apiece, but frankly, it's not like we nurses are sitting around that last hour of the shift, either.

2. Even though night shift is now supposed to do the accuchecks, we are not supposed to stay late to do them, and we are to communicate to day shift which have not been done.

3. The patient might not tell anyone they've ordered breakfast. Day shift nurses often find patients eating when they come into the room. (But I am really not sure why the day shift techs--who only get up to 7 patients apiece--don't have to share responsibility with this.)

4. If nights do the accuchecks, then days is responsible to cover with the insulin.

To me, this is starting to sound like a very roundabout way of laying it all back onto the night nurses' shoulders, without really coming out and saying so, because in order to keep our techs, who already have the highest patient ratio in the building, it looks to me like the only solution is to do the accuchecks for our techs.

I know other hospitals do this and it goes smoothly. Do any of you have any suggestions we might implement to keep everyone happy and healthy?

[sarahRN482]

Angie, I'm dealing with this situation where I work at as well. I'm fairly new to the hospital and it's much larger than where I worked before. In the new place, the Tech's do the accuchecks and we also have the menu/self ordering system for meals. I really hate it! Where I worked at before the RN's/LPN's did all of their patient's accuchecks, so you knew what they were and when the accucheck was done. Where I work now, very few of the Tech's will report the accuchecks to nurses, which leaves it up to us to remember, along with the 8 million other things, to check what their blood sugar was and give insulin, call the doc, etc. I would much rather do my own accuchecks!

[UM Review RN, ASN, RN]

If I worked day shift, I would probably feel safer rechecking some of these before I medicated the patient.

But that's just me, I guess. We all know how dramatically a blood glucose can change in an hour.

[suzanne4, RN]

It is your facility's responsibility to put it in writing as to how the accuchecks will be done., especially since they have changed the policy. Diabetics do need to eat at certain times or within a certain time frame so as not to interfere with insulin or diabetic pills that are required. Perhaps this should not be a policy in place for diabetics. I would also get feedback from your dieticians as well.

Perhaps dietary can get involved and notify nursing that a tray is being sent...

This new policy of the patient being able to order their tray whenever they want should influence day shift more that any other shift. And if adminstration could put the policy in place, they need another to cover diabetics.

[CritterLover, BSN, RN]

maybe you need better communication with dietary?

is there a way you could flag the diabetic's (or other people having their sugars checked) so that when the tray comes up, the dietary aide knows to leave the tray for the nurse to take into the room?

i'm thinking something on the order that prints in dietary....even though the patient is ordering their own food, there has to be some sort of request in the kitchen so they know what kind of diet the patient is allowed to have. flag it there, so the tray doesn't go into the room until the sugar is checked.

i realize this doesn't help with the question of who does the blood sugar, but it might help get the sugars done before the patient eats.

when i was a tech, i did all of the am blood sugars (i worked nights). usually about 0530-0600 while i was doing foleys and i/os, then i told the night nurse. i don't know, though, who it was that gave the insulin (day or night nurse). where i am now (as an rn), techs arn't allowed to do blood sugars, and i always left them for day shift to check.

i'd be mighty ticked, though, if i was the patient and had my sugar checked in the am by night shift, only to have it rechecked by the day shift nurse to make sure the first reading was accurate.

[CrazyPremed, MSN, RN, NP]

I worked at a hospital years ago as a phlebotomist and - believe it or not - the lab was in charge of performing blood sugars on most floors (even in the OR for the CRNA's). We used to always wonder why we were being hounded by the nurses to get them done on time...

Now that I'm going to nursing school, I can see how important they are. The fact is, patients have to be medicated based upon these results. IMHO, allowing pts to order their own trays and bypass the nurses is like letting pts order their own heparin drips from pharm w/o first checking PTT's! Although this gives the pt more flexiblity, I think that dietary has the responsibility to check with the nurses first before releasing the trays. This policy was probably put into place by one of the head RD's at your institution. I would speak with her/him and find out what they plan to do with the accuchecks. It seems that there is too much of an opportunity for pts to throw off their BG levels by ordering their own trays.

CrazyPremed

[UM Review RN, ASN, RN]

This policy was probably put into place by one of the head RD's at your institution. I would speak with her/him and find out what they plan to do with the accuchecks. It seems that there is too much of an opportunity for pts to throw off their BG levels by ordering their own trays.

This is part of what bothers me. The day shift nurse is medicating based on those numbers, therefore she is legally liable should there ever be a problem.

Dietary isn't responsible. We aren't responsible either, because unless they're very very low or very very high, we don't do anything except record the number.

[UM Review RN, ASN, RN]

Where I work now, very few of the Tech's will report the accuchecks to nurses, which leaves it up to us to remember, along with the 8 million other things, to check what their blood sugar was and give insulin, call the doc, etc. I would much rather do my own accuchecks!

I would suggest that the techs actually write the number and initial it on the MAR. Our system is such that the front of the MAR states "Accuchecks bid" and the time, and the nurse records that it was done. But on the BACK of the MAR are lines for the days and a box to record the actual number, tech's initials, and how many units were given.

There's also a line for comments such as if we find the patient crashing at 0400 and gave OJ, etc.

There's no way I could remember all that information or worse, have the time to hunt iit down.

[UM Review RN, ASN, RN]

It is your facility's responsibility to put it in writing as to how the accuchecks will be done., especially since they have changed the policy

Our hospital policy is rather broad and just states that accuchecks must be done. There's about 12 pages to it, but it's based more on guidelines. Each unit does it the way that best suits them. Nurses do accuchecks in the OB unit, the day shift techs do it for the Ortho unit.

Diabetics do need to eat at certain times or within a certain time frame so as not to interfere with insulin or diabetic pills that are required. Perhaps this should not be a policy in place for diabetics. I would also get feedback from your dieticians as well.

Perhaps dietary can get involved and notify nursing that a tray is being sent...

This new policy of the patient being able to order their tray whenever they want should influence day shift more that any other shift. And if adminstration could put the policy in place, they need another to cover diabetics.

Everyone's struggling to get used to this policy. It gives the patient such a sense of control. When I was a patient in a different hospital that used this system, I loved it. However, it's a nursing nightmare, and almost without exception, the day shift nurses hate the policy.

I'm still sure there's a more sensible way to implement it. Such as what you suggest--if someone's on a special diet, the dietary department and the nurses need to get it together. Even when I called for my tray, it did not come up until the diet was cleared by my nurse.

Why this is not happening here is a mystery to me.

I thank you for your suggestions. Please keep 'em coming. :)

[UM Review RN, ASN, RN]

maybe you need better communication with dietary?

is there a way you could flag the diabetic's (or other people having their sugars checked) so that when the tray comes up, the dietary aide knows to leave the tray for the nurse to take into the room?

well, a lot of the girls are saying that they're gonna wind up getting stuck with this duty next. i shudder to think of it! they already have assessments and med passes and all of that day shift drama to deal with.

i'm thinking something on the order that prints in dietary....even though the patient is ordering their own food, there has to be some sort of request in the kitchen so they know what kind of diet the patient is allowed to have. flag it there, so the tray doesn't go into the room until the sugar is checked.

i like this because it'll assure that dietary asks before the tray is set up in the room in front of the patient.

i realize this doesn't help with the question of who does the blood sugar, but it might help get the sugars done before the patient eats.

when i was a tech, i did all of the am blood sugars (i worked nights). usually about 0530-0600 while i was doing foleys and i/os, then i told the night nurse. i don't know, though, who it was that gave the insulin (day or night nurse). where i am now (as an rn), techs arn't allowed to do blood sugars, and i always left them for day shift to check.

see, this is where the nurse uses her discretion. i've gotten hung up and unable to get into the room within a half-hour of the accucheck--this would be for our enteral-feed patients--and have had to repeat it before i medicated them. most of the time, no problem. but there are a couple of times, enough to give me pause, that the cap. blood glucose was significantly different than the earlier reading and could've caused me to give too much insulin.

i'd be mighty ticked, though, if i was the patient and had my sugar checked in the am by night shift, only to have it rechecked by the day shift nurse to make sure the first reading was accurate.

i usually ask first. an alert, oriented, compliant diabetic usually knows way more about her responses than i do, and i tell the patient that, too. usually they're ok with it, but if not, it's ok. they're going to eat a meal, after all.