Insulin drips patients on L&D

[Upgrading_Status, BSN, MSN, RN, NP]

Does this occur in your facility?

Is this common or are they transferred to ICU?

What is your facilities policy regarding pregnant patients needing insulin drips?

[PeakRN]

At our medical center mom would be admitted to the ICU, but we would have an L&D nurse come and monitor the fetus if needed. Our policy dictates that insulin drips can only be given in the ED, ICUs, PICU, or NICUs; it cannot be be given in other critical care nursing areas (be it L&D, PACU, BMT, or others).

Off the top of my head I don't know of any L&D units that give IV insulin drips.

[klone, MSN, RN]

Yes, in the last three facilities I've worked at, the nurses could do insulin drips in L&D. The concern is that they are very high acuity, requiring 1:1 nursing care. Patients in labor should be getting 1:1 care anyway. It's just a matter of making sure the nurse is trained and competent. An inservice, some healthstreams, and a competency checklist is all you need.

[klone, MSN, RN]

9 hours ago, PeakRN said:

At our medical center mom would be admitted to the ICU, but we would have an L&D nurse come and monitor the fetus if needed.

And what do they do with her when she's in labor? Surely they don't expect her to labor and deliver in the ICU.

[PeakRN]

7 minutes ago, klone said:

And what do they do with her when she's in labor? Surely they don't expect her to labor and deliver in the ICU.

If the patient is in DKA or HHNS we don't want them laboring at all. Depending on the presentation this may mean a section but usually would just result in us giving tocolytics.

But to your question, yes we can and have labored patients in the ICU. These are often vented patients or those on pressors though. Again the clinical situation often dictates a section but that is 100%.

The problem isn't about the insulin or their glucose but why that are on an insulin drip. The pathology of diabetic crisis is very high risk. If you are closing the gap or driving down sugars you should be running hourly sugars as well as gasses/lytes at least every 3 hours.

It is unfair to the nursing staff and unsafe for the patient to have that level of intensive care being provided by nurses who are not trained or experienced in it.

While it may not be the calming patient centered experience that we want, we do what is best for the patient. As a regional high risk OB center we have excellent L&D nurses, and we keep as much as we can on the labor deck, but if their presentation requires ICU care then they go to the ICU. This is whether they are an unstable PE, stroke, amniotic fluid embolism, DKA, or countless other critical conditions.

[klone, MSN, RN]

We are a regional high risk OB facility as well. If a critical patient was in labor, we would be more inclined to bring in an ICU nurse to OB, rather than have her labor and deliver in the ICU, which just wouldn't be the best situation for many reasons. But our L&D nurses can handle most situations. Certainly an insulin drip would not preclude being cared for in L&D.

[PeakRN]

23 hours ago, klone said:

We are a regional high risk OB facility as well. If a critical patient was in labor, we would be more inclined to bring in an ICU nurse to OB, rather than have her labor and deliver in the ICU, which just wouldn't be the best situation for many reasons. But our L&D nurses can handle most situations. Certainly an insulin drip would not preclude being cared for in L&D.

I disagree, when we have a laboring patient outside of OB all of our supplies fit into one cart, including our emergency surgical trays. There is no possible way for me to fit all of the ED's or ICU's critical care equipment into one easy to travel package.

The nursing care around OB is much more about experience than supplies compared to intensive care nursing. There isn't going to be CRRT lines on the labor deck nor bronchs, vents, impellas, balloon pumps, a line/cvc kits, chest tube supplies, monitors with multiple invasive pressure setups, and the list goes on. It is our L&D nurses and provider experience that is invaluable, not the labor deck itself.

[klone, MSN, RN]

1 hour ago, PeakRN said:

The nursing care around OB is much more about experience than supplies compared to intensive care nursing. There isn't going to be CRRT lines on the labor deck nor bronchs, vents, impellas, balloon pumps, a line/cvc kits, chest tube supplies, monitors with multiple invasive pressure setups, and the list goes on. It is our L&D nurses and provider experience that is invaluable, not the labor deck itself.

Right, but we're not talking about impellas or CRRT or balloon pumps. You're getting in the weeds. We're talking about an insulin drip. The reason why insulin drips are sent to ICU instead of being managed on med/surg is not because they are so much more complicated that a med/surg nurse can't figure it out, but because they are labor intensive patients that require 1:1 care, which is something that is not feasible on a med/surg floor, where the nurses need to take 4-6 patients, and their productivity cannot support 1:1 care. In OB, the patients are already 1:1 care, so there is absolutely no reason why a labor nurse cannot be trained to take care of a patient on an insulin drip. You're selling yourself and your labor nurse colleagues short if you really think you aren't capable of taking care of a patient on insulin.

[PeakRN]

6 hours ago, klone said:

Right, but we're not talking about impellas or CRRT or balloon pumps. You're getting in the weeds. We're talking about an insulin drip. The reason why insulin drips are sent to ICU instead of being managed on med/surg is not because they are so much more complicated that a med/surg nurse can't figure it out, but because they are labor intensive patients that require 1:1 care, which is something that is not feasible on a med/surg floor, where the nurses need to take 4-6 patients, and their productivity cannot support 1:1 care. In OB, the patients are already 1:1 care, so there is absolutely no reason why a labor nurse cannot be trained to take care of a patient on an insulin drip. You're selling yourself and your labor nurse colleagues short if you really think you aren't capable of taking care of a patient on insulin.

We admit them to the unit because of their disease process: their metabolic acidosis, changing electrolytes that often require replacement, frequent gas interpretation, and so on.

I think our labor nurses are amazing and very skilled their experience averages at over 15 years, but it is 15 years of labor. I wouldn't expect them to be able to come down to the ED and take a trauma that is a 1:1, likewise I wouldn't be comfortable laboring a multip; and a few training modules isn't going to change that.

I think that if our labor nurses wanted to cross train to ICU that they would do great, but it isn't fair to them or the patient to expect them to deliver ICU care on the labor deck.

[ashleyisawesome, BSN, RN]

My unit's protocol is that anyone (with diabetes) in active labor who has 2 blood sugars in a row that are over 100 gets put on an insulin gtt, and yes we titrate them on our unit. The patient is automatically 1:1 and gets hourly blood sugars until they are off the gtt. The gtt is usually d/c'd once they deliver unless they are type 1 DM, then endocrinology is consulted and they decide what to do with it, but they remain on our postpartum unit unless they are in DKA or something and need to move to stepdown or ICU.

I also did insulin gtts when I worked on med/surg, often with a 6 patient assignment.

[Upgrading_Status, BSN, MSN, RN, NP]

On 1/31/2019 at 7:51 PM, klone said:

Yes, in the last three facilities I've worked at, the nurses could do insulin drips in L&D. The concern is that they are very high acuity, requiring 1:1 nursing care. Patients in labor should be getting 1:1 care anyway. It's just a matter of making sure the nurse is trained and competent. An inservice, some healthstreams, and a competency checklist is all you need.

Most of our patients tend to be early second trimester patients. This demographic of patient is so new to us we don't have a policy, more less healthstreams and a competency checklist. Staffing is a mess, to the point where they know we are supposed to be 1:1 with the drip patient, it may now become 2:1. I'm getting sick thinking about it. I can't say more.

[Upgrading_Status, BSN, MSN, RN, NP]

On 1/31/2019 at 10:37 AM, PeakRN said:

At our medical center mom would be admitted to the ICU, but we would have an L&D nurse come and monitor the fetus if needed. Our policy dictates that insulin drips can only be given in the ED, ICUs, PICU, or NICUs; it cannot be be given in other critical care nursing areas (be it L&D, PACU, BMT, or others).

Off the top of my head I don't know of any L&D units that give IV insulin drips.

I feel as if your institution has their I's dotted and T's crossed.