Insulin drips on the floor!

Specialties Cardiac

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Our post cardiac surgery floor is soon to get patients still on insulin drips from CVICU. We usually have a 5 or 6:1 ratio with 2 or 3 techs for 30 patients. Although we do titrate some drips, the idea of having a patient on hourly fingersticks with drip titration is daunting. We are told the assigned nurse will have only a 4:1 ratio but must take 2 pt's with insulin drips. We have been told that many top cardiac surgery hospitals are doing this and are coping well. Does anyone have experience with insulin drips on the floor and if so, how does the pt cope with 24 fingersticks everyday? Is the a desire to get pt's out of CVICU quicker? I have seen some studies about insulin drips and the decrease in deep sternal wound infections but the studies did not show where these patient were located.

Specializes in cardiac.

I work on a floor similar to yours, pre/post op open hearts, pci, etc and we have insulin drips on our pts. We have 23 beds and 3 nurses (2 RNs and an LPN or 2 LPNs and an RN) sometimes we have a tech. You can do the math on how many pts per nurse. (Keep in mind LPNs cannot take or check orders, draw labs, push meds, titrate or even hang any type of drip even heparin-so for the one RN this makes life interesting:uhoh3: :angryfire ) anyways, other than having to check the sugar every hour which is such a PIA the drips really are not that big of a deal. (That is until the cath lab sends you 4 pts with arterial sheaths in their groin and you've already got 2 on dopamine gtts and 1 on ntg gtt and...I digress. Anyway, maybe I don't see it as a big thing because it has been like that where I work since the beginining but once you adjust to the change and the added work it won't be "so" bad. (I won't comment on how unsafe I think it will to have all the pts your talking about as well as adding this though.) One more thing since your not used to it. Remember that insulin helps draw K+ out of cells. I had a pt that was 2.7 and received a k rider and after the rider was 1.7 due to the insulin gtt!! To date the lowest K level I've seen (and with NO compliactions thankfully- though I don't know how she didn't have problems!)

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Turquoise, your situation sounds very bad. Check with your state board of nursing. Basically you have 2 RN's taking care of WAAAY too many dangerously sick people. Your nurse manager, DON and administration should be ashamed of themselves for putting all those lives at risk!

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"I am trying to find statistics from the "top hospitals" using insulin drips"

Not sure how you'd define 'top hospitals',but we're up there--Magnet status,JCAHo-accredited,and we've won a few state and national awards for organizational and healthcare excellence. We do a little over 300 CABG's a year and do them pretty well. My home floor is the Surgical Intermediate unit--mostly post-op cardiovascular surgery but we'll get ortho,uro,general surg,gyn post-ops as well if they need tele but aren't sick enough to be in the ICU,plus just about any medical patient you can think of if another floor is full or swamped. 31-bed unit. AM staffing is usually 3:1,4:1 if we're short but we always take acuity into consideration. PM's is usually 4:1,NOCs 5:1. (Day charge has no pt's,PM's takes one,NOCs 2 to 4.) CNA staffing is 4 on AM's,3 on PM's 2 on NOC's assuming full census. One monitor watcher per shift.

Everyone fussed when we started the Euglycemia protocols for our floor but it's not that bad. We invariably have a CNA with those patients and usually we arrange for each person to do every other accucheck. On our protocol,once we've had 3 straight stable readings,we go to Q2H checks. Our Endocrinologists usually have a plan written for the patient once they start taking at least full liquids and we get them off the insulin gtt's as soon as we are able. It's very rare that a post-op CABG stays on the gtt for more than a day after we get them. Yes,it adds to acuity and workload but we've got an organizational system that responds to those sorts of needs and our budget was recently changed to reflect the higher acuity of our patient population. A year ago,we did around 150 accuchecks a week on the floor. Now we do around 800. Later this year when EVERY patient (not just post-ops and ICU pt's) goes onto the Euglycemia protocol,we project 1500 per week. The results of these efforts so far have shown 50 to 110-point drops in average blood glucoses on the surgical floors. Amazingly,this all occurs in the context of a dietary system that is basically room service--patients call the kitchen and order off the menu and their breakfast might come anytime between 0630 and 0900.

In other words,if your institution will take into consideration the extra work needed to follow a patient with an insulin drip,it's not that bad and it is quite doable. I cringe when I read some of the staffing ratios other similar units have--no way would we be able to properly take care of 5 or 6 of our typical patients on our own.

"Our hospital, like many others, is hoping to get magnet status but they still do not want to include staff nurses in the larger decisions that will affect them the most"--If so,tell them not to even bother filing the Magnet application,cuz they'd be wasting their time.

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On our Neuro Med-Surg we will often have a insulin drip pt cause they "need a ccu bed" the doctor then puts them in another category of care AMSU, advanced med-surg something and staffing has to give us another Nurse. That nurse can only have 3 patients which include that pt and 2 stable pts that are not being discharged so the nurse wont get an admission. the problem with this is the patient gets taken off the insulin drip too quickly for budget reasons, then the nurse gets back a full load of patients and a unstable pt. =(

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Hi,

A little over a year ago we started doing insulin gtts on our telemetry units for our post open hearts. We were told a 3:1 ratio for those nurses with the gtts but lets just say it was 4:1 days 5:1 nights. Unfortunaly if you were short that night you would have 6:1 (which was a problem). I moved to an all medical telemetry floor in January and we do preop open hearts, pre/post pacemaker and ICD's on insulin gtts(depending if they are diabetic, and the doctor) I have a 5:1 ratio. I had a gtt the other night with 5 patients. It keeps me constantly busy but luckily I work with great staff who usually take the fingersticks for me until I can get all my assessments, meds, etc taken care of for my other four patients. The gtts are time consuming and will keep you on your toes all night. I think a lower ratio would be nice but I also know where I work....its an impossible request.

Good Luck!!!

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Specializes in Adult tele, peds psych, peds crit care.

We do insulin drips on our tele floor and I believe the plan is to move to the tight controls in the near future, but that's not why I called. ;)

We had a situation about a month or so ago. A particular nurse who is a real pain to everyone ("that's getting written up, this is getting written up, I'm not putting my pt on a bedpan, that's the aide's job- if they want me to do that, they can pay me nurse+aide pay", etc etc etc)... Well, she had a pt with glucs in the 400's so they started a drip.. 6 hours later she couldn't understand why her patient's gluc wasn't dropping despite the fact that she kept turning up the rate. Another nurse was curious as well so she went in and checked (then came to get me to verify the 'why' before going to the nurse).. and she found a puddle of insulin on the floor be the bed... The nurse never connected the drip to the patient... At which time she, of course, blamed the aide saying "she must have disconnected it or something because I know I connected it!!"... This nurse, by the way, has 17+ years experience...:nono:

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I worked a med/surg unit where we had insulin drips. They could be challenging, particularly if the pt required stat labs in addition to the frequent fingersticks. Management's logic was that a pt. didn't need to occupy a monitored bed simply for insulin drips. This was a small 80-bed hospital. Fortunately, we didn't have too many on insulin drips.........We also didn't have too many needing bedside conscious sedation.........We also didn't have too many tele pts needing to be transferred to ICU......... You get my point!;)

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My hospital would like to develop an insulin protocol. I am in charge of researching if medical surgical floors are safe and appropriate for insulin drips. I have mixed opinions. While, I think that the patients may not be critical enough to warrant and ICU bed, I do think that an ICU staffing pattern would make for a much safer environment

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Specializes in cardiac.

I work on a med-surg tele floor, ratios 5:1 days, 6:1 nights, with 3 CNA's if we are lucky. We have patients with insulin drips occasionally, and no change in ratio to go along with...

As for the CNA getting the accucheck, why bother as she will just have to hunt down the nurse to tell her what it is and then the nurse has to go adjust the drip, may as well do "one stop shopping" and get it done by myself!

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I've worked on a step down cardiac surgery unit for a little over 5 years now...we've always taken insulin gtts. It's protocol for them to stay on the gtt for a minimum of three days and post op hearts come out of the CVICU at 24 hours, if not the same day of surgery. It wasn't easy for me at first, but I found my rhythm with them. We also have good CNA staffing and they do ALL blood glucose levels and document them on the insulin gtt flow sheet. I rarely forget to look (although it does happen occasionally) but if a patient is below 100 (we shut off the insulin if )

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Hi Allele

Thanks for the info. You ratios are better than ours. If we had a 3:1 ratio an insulin gtt would be a piece of cake. What part of the country are you in?

My biggest problem with this whole situation is that the people who decide what the bedside nurse can "handle" does not work at the bedside and probably hasn't in many years. There is no accounting for acuity of patients or for the type of surgery/disease process. They use these formulas to calculate how many nurses needed per shift that are totally inadequate because of the above factors. Administration throws extra money or high differentials at nurses and thinks this will keep patients safer.

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Hi Allele

Thanks for the info. You ratios are better than ours. If we had a 3:1 ratio an insulin gtt would be a piece of cake. What part of the country are you in?

My biggest problem with this whole situation is that the people who decide what the bedside nurse can "handle" does not work at the bedside and probably hasn't in many years. There is no accounting for acuity of patients or for the type of surgery/disease process. They use these formulas to calculate how many nurses needed per shift that are totally inadequate because of the above factors. Administration throws extra money or high differentials at nurses and thinks this will keep patients safer.

I have to agree with you. The people who get to decide how many patients we can take care of are pretty far removed from reality sometimes. I know I'm lucky where I am...I've worked in a few hospitals through some agency work I did and my full time job certainly has the best ratios I've seen. I'm in the Northeast, if you'd like more specific information I can PM you if you'd like. Good luck with your situation! :)

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