Insulin and Innovative Approaches

In June, I attended the ADA’s 69th Scientific Sessions Conference that was held in New Orleans this year. Among other presentations, I listened to Mary Sullivan’s very interesting talk offering practical advice on better inpatient diabetes care. We’ve written numerous times online about how hospital glycemic control needs to be improved. For example, you can read our article on called, “U.S. Academic Medical Centers Are Not Cutting the Mustard.”

Mary Sullivan, RN, MSN, APRN, BC, CDE, Diabetes Clinical Nurse Specialist, is an Assistant Clinical Professor in the Department of Family Health Care Nursing at UCSF School of Nursing. She outlined a program Dr. Gary Arsham, MD, developed; a training module for healthcare professionals whose goal is to minimize medication/insulin errors.

Insulin is one of the top five medications with the greatest risk of causing harm when medication errors occur. Over-worked nurses need a broad spectrum of knowledge on a multitude of medical conditions so it’s difficult to know everything they need to know about diabetes and insulin administration. Dr. Arsham’s team created and evaluated the impact of a computer-based training module for reducing “insulin misadventures” by nurses caring for hospitalized pediatric patients.

Pediatric nurses were required to complete an online training module. The course covered general background on diabetes, insulin pharmacodynamics, explanations of each part of the insulin order form, how to interpret orders for diluted insulin, and examples of possible orders. There were also 15 questions to test the ability to interpret orders and deliver the appropriate insulin dose. A retrospective chart audit of all patients receiving insulin was done both pre and post- training module. Insulin administration errors decreased from 14% pre-training to 2% (p<0.04) sustained over six months.

Mary Sullivan also presented some simple adjustments that can make a world of difference in the care of patients with diabetes such as not giving a patient their meal until after the medical staff has administered the patient’s insulin. It’s difficult to gauge how much insulin the patient needs when they have already completed their meal.

Dr. Arsham’s program turned out to be a successful strategy for reducing inpatient insulin errors and it’s exciting to learn how diabetes care can benefit from advanced technology. For more on technology and diabetes, read the article in this issue about iPhones and diabetes.

Insulin remains the most powerful diabetes medicine and, of course, it’s indispensable treatment for people with type 1 diabetes, in which the body no longer produces its own insulin. The first line of defense for people with type 2 diabetes (since they usually still make some insulin) is typically oral BG-lowering. But type 2 is a progressive disease and people with this form of diabetes usually require insulin supplementation over the course of their care regardless of how well they take care of themselves.

A study published in the May 24, 2008 issue of The Lancet found that when newly diagnosed type 2 patients began insulin therapy right away it gave them better blood glucose control than with the oral medications.

But there is lots of resistance to taking insulin. As our Guest Editor, Deborah Greenwood, MEd, CNS, BC-ADM, CDE, points out in her column, it’s not just the patients who are resistant to the idea of insulin. She writes, “Although the 2009 ADA guidelines recommend insulin as an early therapy to improve glycemic control, insulin continues to be started later than needed. It is often used as a ‘threat’ to motivate patients to follow their meal plan and exercise. Unfortunately, years of such tactics have created a negative image for insulin, preventing its use by many patients who really need it.”

Innovative programs such as the one at Greenwood’s Sutter Medical Foundation, and Dr. Arsham’s and Mary Sullivan’s at UCSF are really exciting. They demonstrate that successful efforts are being made to educate both healthcare providers and patients about insulin and other medications, a decidedly win-win situation.

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