By: Marie McCarren
Take this test on insulin and see if you can get a higher score than hospital doctors and nurses.
When you first heard about the game show “Are You Smarter Than a 5th Grader?” maybe you thought, “Of course an adult will be able to answer a first-grade science question, or a second-grade geography question.”
Then you watched the show.
“Which of the Great Lakes lies farthest east?” Um… Erie? “In the Northern Hemisphere, the summer solstice occurs in which month?” Let’s see…August is the hottest month, so…
It’s not so easy when you’re 5, 10, or 20 years past elementary school.
Now imagine you’re a doctor working in a hospital. You are not an endocrinologist. You learned a little about diabetes in medical school. Over the years, you’ve had opportunities to take continuing education courses on diabetes and workshops on new insulins sponsored by the manufacturers. But there were always other courses about diseases you see more often.
A patient who uses insulin is admitted. It’s your responsibility to give the medication orders. Will you make the right decisions?
Researchers at Johns Hopkins University in Baltimore gave an anonymous survey about insulin to 377 doctors and nurses from four teaching hospitals in the Baltimore area. The goal of the researchers was to identify topics for educational programs.
Those surveyed included internal medicine faculty members, house staff, nurses, interns, and second- and third-year residents. Specialty faculty included those in cardiology, geriatric medicine, gastroenterology, pulmonary, and nephrology.
The doctors and nurses were given about 10 minutes to complete the survey. They could not ask others for help or check books.
Some of the questions are quite technical, but you might like to take a stab at the test before you read the answers and see how the doctors and nurses did.
Department of Medicine Insulin Use Knowledge Assessment
1. Humulin is:
An insulin brand name
2. 75/25 is:
75% NPH, 25% lente
75% protamine, 25% glargine
75% protamine, 25% regular
75% protamine, 25% lispro
3. 70/30 is:
70% NPH, 30% regular
70% NPH, 30% glargine
70% protamine, 30% lispro
70% glargine, 30% aspart
4. Glargine is:
5. In general, a rapid-acting insulin:
Peaks within 6 to 8 hours
Peaks within 2 to 4 hours
Peaks within 1 hour
Has no peak
6. In general NPH insulin:
Peaks within 4 to 10 hours
Peaks within 12 to 24 hours
Peaks within 2 to 4 hours
Has no peak
7. Which of the following cannot be physically mixed in the same syringe with other types of insulin?
8.Which of the following is a cloudy, rather than a clear, solution?
9. Commercially available insulin pumps:
Need to be surgically inserted
Use NPH insulin
Use rapid-acting insulin
Provide basal insulin only
10. The American Diabetes Association definition of hypoglycemia is a blood level less than:
11. In order to avoid complications, when a type 1 patient is NPO (“nothing by mouth,” that is, not eating or drinking):
Discontinue all insulin
Continue basal insulin
Continue only sliding scale insulin
Continue only rapid-acting insulin
12. Sliding scale insulin is best used:
a. To meet basal insulin requirements
b. To cover carbohydrates eaten in meals
c. As a supplement to scheduled insulin to correct hyperglycemia
d. As a guide for making changes to scheduled insulin doses
a & b
b & c
c & d
All of the above
13. A typical daily insulin requirement for an adult with type 1 diabetes:
14. What percentage of the daily insulin requirement does basal insulin generally account for?
15. Diabetic ketoacidosis (DKA) can develop in:
Type 1 diabetes only
Type 2 diabetes only
Both type 1 and type 2
None of the above
16. In DKA, when converting from a continuous insulin infusion to subcutaneous insulin, start subcutaneous insulin approximately:
2 hours before stopping the infusion
At the same time as stopping the infusion
1 hour after stopping the infusion
4 hours after stopping the infusion
Answers and Results
We’ll list the groups that did the best and the worst on each question.
1. Humulin is an insulin brand name.
Answered correctly by 65 percent of specialty faculty but only 21 percent of interns. Many test-takers answered that it is a rapid-acting insulin, perhaps confusing Humulin with Humalog.
2. 75/25 is 75% protamine/25% lispro.
This question stumped the most people. It was answered correctly by only 22 percent of third-year residents and 3 percent of specialty faculty.
3. 70/30 insulin has been around a long time, and most test-takers (88-95 percent in each group) knew that it is 70% NPH/30% regular.
4. Almost all of the third-year residents (97 percent) but only a third of the nurses with 6-10 years experience knew that glargine is a basal insulin.
5. In general, a rapid-acting insulin peaks within 1 hour.
What a difference a year makes: 49 percent of interns (first-year residents) and 74 percent of second-year residents got this right.
6. In general, NPH insulin peaks within 4-10 hours.
Answered correctly by 64 percent of the interns, and 82 percent of second-year residents.
7. Most third-year residents (88 percent) but only 48 percent of specialty faculty knew that glargine cannot be mixed with other insulins.
8. Almost all of the nurses (97-99 percent) knew that NPH is cloudy. Only 25 percent of specialty faculty knew this.
9. Commercially available insulin pumps use rapid-acting insulin.
Only 32 percent of nurses with less than 5 years experience but 63 percent of third-year residents knew this.
10. The ADA definition of hypoglycemia is a blood glucose less than 70 mg/dl.
Specialty faculty finally stepped up: 48 percent got it right, versus 34 percent of nurses with more than 10 years experience.
11. If you’re NPO, hope that a third-year resident is writing your insulin orders: 81 percent of them knew to continue basal insulin, but only 12 percent of nurses with more than 10 years experience knew this.
The researchers write: “Recognition that patients with type 1 diabetes require basal insulin at all times is crucial because stopping insulin can result in DKA and death. Nevertheless, 25 percent of all house staff and the majority of faculty and nurses answered this question incorrectly.”
12. Sliding-scale insulin is best used as a supplement to scheduled insulin to correct hyperglycemia and as a guide for making changes to scheduled insulin doses.
Answered correctly by 53 percent of third-year residents, but fewer than 20 percent of the nurses.
13. A typical daily insulin requirement for an adult with type 1 diabetes is 0.5-0.7 units/kg.
Answered correctly by 71 percent of second-year residents, and 24 percent of nurses with more than 10 years experience.
14. Basal insulin generally accounts for 40-50% of the daily insulin requirement.
Answered correctly by 60 percent of first-year residents, and 14 percent of nurses with 6-10 years experience.
15. Most of the test-takers knew that DKA can develop in both type 1 and type 2 diabetes; 97 percent of third-year residents, 71 percent of nurses with more than 10 years experience, and even 80 percent of the specialty faculty got this right.
16. In DKA, start insulin shots about 2 hours before stopping the insulin infusion.
Most third-year residents (93 percent) but only 32 percent of nurses with less than 5 years experience knew this.
Peek, Copy, and Save
In their quest to win a million dollars, contestants on the Fox game show can “peek” and “copy” from the bright fifth-graders in the show’s “class.” The Baltimore researchers note that in a real world situation, doctors would be able to ask colleagues if they weren’t sure of what to do. But there’s the rub. One of the questions in the survey was, “How comfortable do you feel medically managing patients with diabetes?” The researchers report: “[G]iven that most respondents self-reported feeling very or somewhat comfortable in diabetes management, we may reasonably expect that many would not seek additional information when confronted in the clinical setting with diabetes management issues addressed by our questionnaire.”
On the TV show, a contestant who answers incorrectly can once – and only once – be “saved” if his or her chosen fifth-grader has the correct answer. Does this happen in hospitals? Yes. If a doctor give orders for an inappropriate dose of insulin, the nurse can say, “Are you sure this is the right dose?” But this study shows that not all nurses know the appropriate doses.
What should you do if you are in the hospital? Rachel L. Derr, MD, a senior fellow in endocrinology and metabolism at the Johns Hopkins School of Medicine, and Annabelle Rodriguez, MD, director of the Diabetes Management Service at Johns Hopkins Bayview Medical Center, offer this advice:
- If you have type 1 diabetes, you are not eating, you’re not being given insulin shots, and you’re on IV fluids, ask whether the IV fluids contain insulin. Remember, you need some insulin even when you’re not eating. (People with type 2 diabetes may be making enough insulin of their own to avoid DKA.)
- Every time you are being given insulin, ask, “What dose are you giving me?” If it sounds wrong, say, “That doesn’t sound right. Can I speak to the doctor?”
- You can always ask for a consultation from an endocrinologist or the inpatient diabetes team. Many hospitals in the United States are now establishing such teams to increase patient safety.
- It’s hard to speak up and question doctors and nurses. But you know your body and your typical insulin doses better than anyone at that hospital. It may fall to you to make the save. And the stakes are higher than a million dollars.
Marie McCarren is the author of Guide to Insulin & Type 2 Diabetes and A Field Guide to Type 2 Diabetes. The answers are “Lake Ontario” and “June.”