Diabetes Management in Phase II Recovery

[AnnoyedNurse]

Hi Nurses!

So I have a question about diabetes management in Phase 2 recovery of the ambulatory surgical patient. It seems to be standard of cafe in Phase 1 (PACU) to get a POCT blood sugar upon admission and treat hyperglycemia if it is greater than 200 or 300 depending on the anesthesiologist.

In Phase II or post-op, is it the standard of care to immediately recheck the blood sugar upon admission to Phase II?

My practice and the nurses practice who I work with in Phase two has been to check the blood sugar only on patients who are symptomatic, the patient states they "feel" like their blood sugar is high, OR if a doctor's order is in place such as AC/HS.

Further, if a patient is symptomatic, i.e. polyuria, and you do recheck the BS and is elevated, and the family and the patient refuse the insulin, the nurse informs the doctor, does this fall back on the nurse, the physician, or the family?

There seems to be a confusion with one of our new managers on a unit I work at Per Diem and she is trying to place blame on the nurse. I've attempyed to research ASPAN guidelines but I am unable to find anything specific to Phase 2 recovery. Your opinions and links to articles would be helpful.

Thank you!

[brownbook]

I'm so confused. I've worked ambulatory surgery for 17 years.

First of all, how can blood sugar be AC/ HS in ambulatory surgery? Where I've worked nurses have been threatened with incident reports if the patient stays over 2 hours in phase II, and our "meal" is juice and crackers.

Our only protocol is what anesthesia orders. It can vary per different anesthesiologist. But most of them know out patient surgery is not the place to change or "manage" a patient's diabetes.

Unless it is almost critically out of control, (in which case they would be transferred to an in patient facility), the patient is sent home as long as it is within a somewhat normal range for that patient. We occasionally call the patient's primary care physician to let them know their patient's sugar was running high.

I don't understand what the nurse is being blamed for? The nurse informs the doctor the patient refused insulin, end of story.

What does your new manager want the nurse to do? Force the patient to take insulin?

I'm so confused.

Our anesthesiologist reason that in most cases the patient has been managing their diabetes for many years. The anesthesiologist is not going change the patients own routine of care when the have only known and interacted with the patient for a few short hours.

Maybe I'm not understanding your situation, I'm still confused.

[AnnoyedNurse]

We're also very confused why our manager is blaming this nurse. This patient happened to have an ACHS order in place and that's why she checked it. Otherwise she would not have checked it.

[brownbook]

Your manager sounds like an idiot. If it becomes a frequent issue could you ask your medical director to discuss the issue with her?

[brownbook]

Why or who would order AC/HS for an ambulatory surgery patient? Did the patient come with those orders from another facility?

My first out patient ambulatory surgery job was in a clinic that was part of the acute care in patient hospital. Sometimes we'd get these patients. Did this patient come from something like that?

[AnnoyedNurse]

This patient was supposed to be admitted but since surgery went well, the doctor decided admission was no longer necessary, and the ACHS order remained even though she was no longer being admitted.

To add to the situation- our manager is trying to say that we must check blood sugars on ALL DIABETIC PATIENTS upon admission to Phase 2 recovery. She's obviously wrong. I'm going to bring it up in our shaded governance committee and if she persists that she wants to mandate this be standard, I'll escalate to our medical director. Thanks for the suggestion!

[brownbook]

I know next to nothing about billing patients. But if a patient or their insurance is charged for POCT without a doctor's order that could be an issue.

I think insurance companies won't cover a procedure that does NOT have a doctor's order.

A POCT must be ordered by a doctor! A nurse can't arbitrarily order one. Only if a policy or protocol covers it.

You and I would probably be shocked at how much a POCT costs.

[azhiker96, BSN, RN]

In my experience Anesthesia manages blood glucose in the PACU setting. Typically an outpatient with diabetes will get a POCT on admission to Phase I. Depending on the results there may or may not be insulin coverage ordered. If insulin is ordered, anesthesia may want a recheck after an hour or they may be fine with feeding and sending the patient home. It's the doctor's call.

Sometimes I may ask for an order for a blood glucose check if a patient is particularly slow to awaken. I've seen BG in the teens a couple of times. IV glucose perks them right up. Moderately low BG can be addressed with snacks in Phase II.

[djmatte, ADN, MSN, RN, NP]

I don't see any "right" or "wrong" here. The standard of care here is whatever your facility deems important enough to warrant performing. In a few hospitals I worked, any diabetic was absolutely checked for blood sugar levels upon arrival to PACU. All of our diabetic patients had standing orders for a blood glucose if symptomatic. But unit policy spelled out the circumstances to draw it upon arrival. We didn't in phase II unless symptomatic, but if your boss has a different plan and there is policy/procedures that reinforce that plan then that is the standard of care at your hospital.

[AnnoyedNurse]

Djmatte- Thanks for your insight. I did clarify with our Senior manager that blood sugar checks upon admission to Phase II is NOT the standard. But to state that just because my boss has a plan in her mind makes it the standard contradicts the very basis of evidence based practice. If the hospital has a policy that is not the standard, then we still follow it because it's hospital policy. If there is no specific policy, then we follow the standards based on evidence. In this situation, there is no policy that states we must check blood sugar on every single diabetic upon admission to Phase II- only when symptomatic or there exists another reason such as an Provider order or holding the patient for a long period of time and having to provide them a tray; therefore I was looking for more insight based on the practice of others if supported by literature. (Phase I it is mandated by the standards set forth by ASPAN and ASA).