Question on Pediatric Insulin Administration

classicdame, MSN, EdD · Aug 3, 2009

to begin with - the ADA and the Am. College of Clinical Endocrinologists published a position statement a few years ago that stated SSI is "non-effective and not recommended". The preferred method is basal plus correction doses of fast-acting. There should be a nursing protocol for that on your unit. If not, you need to find one and find the science behind it to get a new P&P written. The Academy of Pediatrics, ADA and others will have samples. The Medical staff has to approve, of course. You are right, it is ridiculous to make patients wait. I suspect this is a teaching hospital and someone thinks this is how the resident keeps tabs on diabetics, but in reality the patient is not being served and the resident is making shotgun decisions. Recipe for disaster.

*ac* · Aug 3, 2009

Our patients WAIT.

Only the on-call endocrinologist can make the dosing decision. This is because the carb-ratio and correction factor is different for each child and is often adjusted q dose.

I really can't imagine standing orders for insulin in pediatrics.

So, the nurse pages the intern with the blood sugar, ketones, and carb count. The intern must then page the endo; after they discuss, the intern enters the order and the nurse can proceed.

ChristineN, BSN, RN · Aug 3, 2009

to begin with - the ADA and the Am. College of Clinical Endocrinologists published a position statement a few years ago that stated SSI is "non-effective and not recommended". The preferred method is basal plus correction doses of fast-acting. There should be a nursing protocol for that on your unit. If not, you need to find one and find the science behind it to get a new P&P written. The Academy of Pediatrics, ADA and others will have samples. The Medical staff has to approve, of course. You are right, it is ridiculous to make patients wait. I suspect this is a teaching hospital and someone thinks this is how the resident keeps tabs on diabetics, but in reality the patient is not being served and the resident is making shotgun decisions. Recipe for disaster.

Yes, from my research I am aware of the current research against a sliding scale only, which is why I also stated carb counting, as many of the patients I see, at home, have a sliding scale to cover their high number, and a carb counting ratio to cover their meal. Yes, this is indeed a "teaching hospital." I have not check the Academy of Pediatrics or ADA yet, I will have to look there.

ChristineN, BSN, RN · Aug 3, 2009

Our patients WAIT.
Only the on-call endocrinologist can make the dosing decision. This is because the carb-ratio and correction factor is different for each child and is often adjusted q dose.
I really can't imagine standing orders for insulin in pediatrics.
So, the nurse pages the intern with the blood sugar, ketones, and carb count. The intern must then page the endo; after they discuss, the intern enters the order and the nurse can proceed.

Ac, this is how we do it too. However, for our known diabetic patients, we are not changing their home regimens (unles they are in for DKA or poor control issues). If one of the diabetic patients is in for, say, a T&A, why shouldn't the nursing staff be allowed to have standing orders? I am talking about standing orders for the stable, well controlled ped diabetic patient. Keep in mind that I realize we would still need one time, individual orders for the newly diagnosed diabetic patients.

*ac* · Aug 3, 2009

In almost 2 years of acute care pediatrics, I have never had a "known" stable diabetic peds patient. They've all been newly dx or dka. I'm sure there are such pts, but we have a 30+ bed unit, so they must be pretty rare.

In talking with our endo, I would venture that the stable, well-controlled ped diabetic pt is a fairly rare species, anyway. Kids are always changing. Even if they were otherwise controlled, coming in for surgery would most certainly require changes from their normal home regimen. The stress of surgery alone is likely to require higher insulin doses, not to mention interference of any meds (such as steroids for asthma, etc).

ChristineN, BSN, RN · Aug 3, 2009

In almost 2 years of acute care pediatrics, I have never had a "known" diabetic peds patient. They've all been newly dx or dka. I'm sure there are such pts, but we have a 30+ bed unit, so they must be pretty rare.

I work at a large peds hospital whose outpatient pediatric diabetic clinic sees over 1200 patients. My facility believes in barring a trauma or critical care related admission, all diabetics belong on my floor. As a result, I see the well controlled that came in with a wound infection, the toddler that's in for a sedated colonoscopy, the kids that get their T&A's, etc. Granted the knowns are not the bulk of the diabetics, but at this point the nursing staff on my floor is so frustrated with the wait time patients have to spend waiting for insulin orders, even if the doctor is following a home regimen, that at this point we'll try anything to decrease their wait time.

I don't know how it works at your facility, but it's not uncommon for my pts to have to wait 45min + for an insulin order. I feel that even for the newly diagnosed that there must be some way to decrease their wait time some.

ChristineN, BSN, RN · Aug 3, 2009

In talking with our endo, I would venture that the stable, well-controlled ped diabetic pt is a fairly rare species, anyway. Kids are always changing. Even if they were otherwise controlled, coming in for surgery would most certainly require changes from their normal home regimen. The stress of surgery alone is likely to require higher insulin doses, not to mention interference of any meds (such as steroids for asthma, etc).

Depending what's going on, 9 times out of 10 we don't have to change their insulin regimen. When I see inpatient diabetics with pumps, they are allowed to stay on their home regimen, with much more control for nursing, why can't it be this way for knowns that are not on a pump? I have found some facilities (not many) that have standing peds orders for knowns.

*ac* · Aug 3, 2009

Depending what's going on, 9 times out of 10 we don't have to change their insulin regimen. When I see inpatient diabetics with pumps, they are allowed to stay on their home regimen, with much more control for nursing, why can't it be this way for knowns that are not on a pump? I have found some facilities (not many) that have standing peds orders for knowns.

Just speaking from my own experience.

ChristineN, BSN, RN · Aug 3, 2009

Just speaking from my own experience.

Don't misunderstand, I'm grateful for your feedback. You are reinforcing my thought that standing orders are not that common in pediatrics. I believe, though, as nurses are given more autonomy, that this is something we will see more of.

*ac* · Aug 3, 2009

Don't misunderstand, I'm grateful for your feedback. You are reinforcing my thought that standing orders are not that common in pediatrics. I believe, though, as nurses are given more autonomy, that this is something we will see more of.

At my hospital, even the chief residents don't have that autonomy; there's no way the nurses will get it. As I said, only the attending endocrinologist makes dosing decisions.

ChristineN, BSN, RN · Aug 3, 2009

At my hospital, even the chief residents don't have that autonomy; there's no way the nurses will get it. As I said, only the attending endocrinologist makes dosing decisions.

Wow. At my facility we have endocrinology fellows that typically determine the insulin orders. However, for our knowns, they may have in their progress note "continue following this X plan from home" but unfortunately, it is currently against hospital policy for their to be a standing order for insulin so they are not allowed to just write an order to continue following the home regimen.

Does your facility even use fellows? I would think it'd be easier to get a hold of the fellow than the attending.

I think that there will have to be some clear cut guidelines if I am able to institute a standing order. For example, all insulin doses would be checked with another RN to verify accuracy, and the doctor would still be notified when the pt has ketones, as well as being notified if blood sugar goes above a certain pre-determined amount.