We investigated the incidence of timing problems with insulin-related processes in a subacute inpatient unit in Melbourne and found that nursing staff often conduct blood glucose level (BGL) testing longer than 30 minutes before insulin administration (between 22% and 41%). Nurses are better at administering rapid-acting insulin doses within the recommended time before food intake (94%) than conventional insulin analogue doses (43%). BGL testing is carried out too early due to established ward practices and busy mornings, as well as poor guidance from an outdated policy. The timing of conventional insulin analogue administration is by nature more complex than that of rapid-acting analogues. Current timing places inpatients at risk of harm from hypoglycaemia. The high level of care demand in our subacute unit contributed to timing problems, and this is likely to be a problem in other units. Process redesign, policy revision and staff education could be used to reduce the risk of hypoglycaemia in this subacute inpatient unit.
Aust Health Rev 2004: 28(2): 61-67
The problem of insulin administration processes at Broadmeadows Health Service
BROADMEADOWS HEALTH SERVICE (BHS) is one of the four campuses of the Northern Metropolitan Health Service in Melbourne, Victoria. Broadmeadows Health Service is an Integrated Care Centre which provides subacute inpatient palliative care, rehabilitation, and geriatric evaluation and management (GEM) services, among others, to the population in Melbourne's north-western suburbs from the Hume-Moreland Local Government Area. BHS Rehabilitation and GEM Units provide subacute inpatient services to a mainly older patient population with high level care needs and complex health and social needs. Up to 30% of BHS inpatients have diabetes, and up to 10% of inpatients may be administered insulin during their hospital stay.
Process mapping of insulin administration in 2002 highlighted differences in practice across inpatient units relating to capillary blood glucose level (BGL) monitoring and insulin administration. The timing of BGL measurements was also inconsistent with best practice diabetes management guidelines. A limited-scope audit in June 2003 suggested that improper timing of pre-meal insulin was a problem in the BHS inpatient units, placing inpatients at risk of experiencing hypoglycaemia.
Factors affecting insulin administration processes
The workload challenges faced by nurses in the subacute setting are different to those experienced in acute care. These challenges include the high level care needs of mainly elderly patients with complex health and social needs, the difference in the nursing ratio and skill mix in comparison to the acute setting, and the number of tasks that need to be completed first thing in the morning to ensure the patients can attend allied health and other appointments.
Despite the increased complexity of subacute patients' care needs, the expectation to reduce length of stay (LOS) and maintain a high bedoccupancy rate has remained. The Rehabilitation Unit decreased its LOS within the last year and the acuity of patients has increased, increasing the workload for nurses and allied health despite staffing increases. Subacute units have a higher proportion of Division 2 nurses than acute units. In Victoria, while there are moves to change this, Division 2 nurses are not allowed to administer medications and complete some other patient care tasks, which shifts significant workload to the Division 1 nurses.
Currently, one morning medication round of 10 patients may take 2 hours to complete. This is due to the average patient being administered 9 to 11 medications per round and the complex medication administration systems on two inpatient units. Because the medication rounds take so long to complete, the nurses find that during the last hour of the medication round they are often interrupted, as patients demand more assistance and allied health and medical staff start their shifts. …