Maine Medical Center Portland, Maine Kate Hawley, LD

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Maine Medical CenterPortland, Maine Kate
Hawley, LD
Kathy received her bachelors degree in Nutrition
from the University of Maine at Orono, and her
masters degree in Adult Education from the
University of Southern Maine. She is a
Registered/Licensed Dietitian. Kathy presently
works as the Manager of the Maine Medical Center
Department of Clinical Nutrition and Patient
Services.
Kathleen Halpin, MS, RD/LD
Kate Hawley graduated from the University of
Rhode Island with a degree in Dietetics and
became a licensed dietician in 2006. She is
currently working as a Clinical Dietician at
Maine Medical Center covering surgical and
prenatal care units. Kate specializes in
inpatient diabetes management and has been
working with the multidisciplinary team to
develop the MMC glycemic protocols.
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Integrating Carbohydrate Counting into your
Insulin Protocols

• Kathy Halpin, MS, RD/LD
• Kate Hawley, RD/LD

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Objectives

• Discuss our experience with converting to CHO
  controlled diet
• Share MMC nutrition services experience with
  implementing/role in insulin protocols
• Suggestions/thoughts as to how your nutrition
  department can aid in developing protocols

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Brainstorming

• Determine if what you have works or does not work
• Get opinions from staff members outside your
  department
• Do you have the resources to make a change
• If you do want to make a change carefully assess
  what will work best
• Will your administration support a change ?

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Will a change create a better outcome?

• Is it effective in aiding in better glycemic
  control?
• Consider all factors hospitals current
  policy/practice on glycemic control
  (?uniform/standardized), compliancy to diet order
  (patient or nutrition department), causes of
  hyperglycemia
• Is it user friendly
• Nursing, Physicians, Patients, nutrition services
• Will it be compatible with insulin protocols?
• Does it assist patients in transition to home
  management
• Do you have support from administration if change
  is necessary

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Why change to CHO controlled diets ?

• Research from hospital protocols, DB research
  studies and patient outcomes indicates it is the
  best approach for optimal glycemic control
• Will the system be compatible for your
  system/hospital
• Give examples
• Easier for prandial insulin dosing
• Current trend for diet management of diabetes
• Patient education, facilitate transition to out
  patient management

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Accountability

• Menu audits for compliancy to current system- Are
  we really complying with diet Rx?
• Initial Tray Audits for calorie controlled diets
• 65 menu/tray tickets audited
• 2400, 2000, 1800, 1600, diabetic diet
• 50 compliant
• 50 non-compliant

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What did MMC decide to do????

• Change to CHO controlled diets using the
  hospitals electronic system, Sunrise Clinical
  manager, and interfacing this with the Nutrition
  departments electronic system called CBORD.

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Decide on the diet orders
Enter parameters for the diet orders into CBORD
Compliances and Pattern Fixing
CBORD Steps
½ portions may be an option
Evaluate the recipes and each food item
All food items and recipes portions need to be
weighed
Adjust portions sizes as needed
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Calories CHO
Carbohydrate/meal Exchanges Total CHO/day (Total Calories)
Breakfast Lunch Dinner
45-59 gm/meal 3-4 3-4 3-4 145-177 gm CHO (1100-1400 kcal)
60-74 gm/meal 4-5 4-5 4-5 180-222 gm CHO (1450-1800)
75-90 gm/meal 5-6 5-6 5-6 225-270 gm CHO (1800-2150)
90-100 gm/meal 6-7 6-7 6-7 285- 315 gm CHO (2150-2400)
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• Work in conjunction with your IS department to
  get diet orders into the hospital system
• Train staff and emphasize need to follow recipe
  and portion size staff will need all the
  right tools
• i.e. various scoops, spoodles, scales
  etc.
• Continuously emphasize to the production staff
  the importance of the accuracy when preparing or
  serving food.
• Communicate Communicate Communicate

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Pattern Fixing

• Pattern Fixing is a CBORD functionality that
  ensures the number of CHO gms on each meal tray
  ticket is not too high or low.
• The CBORD system adjusts patient meal selections
  so that a meals nutrient or dietary exchange
  totals match the patients prescribed diet order.

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Pattern Fixing

• Example
• Patient dietary goal pattern 45 gm at
  breakfast, lunch, dinner- yet the patient selects
  foods totaling 75gm carbohydrates.
• Results The system will remove food item(s) to
  bring the CHO gms within the limits of the diet
  order.

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Once all the steps were completed with the CBORD
system it was time to test the system and view
the tray tickets ! What would they
look like ?
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Tray Ticket
Grams of carbohydrate in food item
Medium range of total carbohydrate in meal
Grams of carbohydrate meal plan ordered
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Post implementation of the CBORD

• Describe our menu audit system
• Show our menu audits
• Share with staff
• Quarterly meetings with NCRs

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Begin Department Staff Training

• Identify which staff need to be trained
• Sample of training topics
• Hospital program
• What is Diabetes ?
• Diet orders
• Role responsibilities
• Portion Control

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Essential items to include in the training

• Imperative to
• Share with staff WHY CHO counting is
  essential, DO NOT minimize the importance
• Bring in what may hit them personally
• Discuss how correct portions impact the budget
  Administration will also like this one
• Portion control Power Point
• House wide on how utilize order (Nursing,
  Physicians)

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Two Teams working for the same Goal
Nutrition Team
CSSP DB TEAM
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MMC Insulin Protocols

• Nutrition Departments role in the creation and
  implementation

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Nutrition Role with Protocol Development

• Integral part of the development team
• Education
• Physicians, RNs, CNAs, RDs
• Responsible for the implementation of CHO
  controlled diets- 50 of insulin needs

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Hyperglycemia at MMC New insulin order sets

• Basal Insulin
• Nutritional Insulin
• Correctional Insulin
• SC protocol
• IV insulin transition
• Hypoglycemia protocol
• TPN TF insulin guidelines
• Steroid insulin guidelines

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Normal patterns of insulin release from the
pancreas during course of a day
Breakfast
Lunch
Dinner
Plasma Insulin
400
1600
2000
2400
400
1200
800
Time
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Basal/ Nutritional Insulin Therapy
Breakfast
Lunch
Dinner
Plasma Insulin
400
1600
2000
2400
400
1200
800
Time
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Continuous TF

Short Acting Insulin For continuous coverage of
CHO in TF q 6 hours

0600 1200
1800 2400
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Education Basal, Nutritional, Correctional

• Nutritional or Prandial Insulin
• Insulin required at meal-time
• Covers rise in blood glucose after carbohydrates
• Amount of insulin necessary to cover
• TPN, ETF, nutritional supplements, or meals
• In general 1 unit per 15 grams
• Lowers BG back to desired target post
  Carbohydrate infusion/ingestion
• Hold nutritional insulin if patient is NPO

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RN education Elements of CHO Counting

• Learn how to relate carbohydrate intake to blood
  glucose levels
• Focus on total carbohydrate versus types of
  carbohydrate
• TF and TPN provides significant source of CHO
• Foods with carbohydrate
• CHO needs are individualized

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Fact Sheets for Nursing

• Nursing will need the CHO content of various food
  items to determine amount of prandial insulin to
  administer
• Nourishment
• In between supplements
• Box meals
• Enteral products
• Foods from the outside

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NOURISHMENTS October 2009
Item Portion Carbohydrate (gms)
Apple Juice 4ox (1/2c) 14
Applesauce ½ c 13
Bread white or wheat 1 slice 13
Broth 6 oz 0
Carnation Instant Breakfast (CIB) w/8oz Whole, Low fat, Skim 1 packet CIB with 8oz milk 39
Carnation Instant Breakfast (CIB) w/8oz Whole, Low fat, Skim with Ice Cream 8 oz milk with ½ c Ice Cream 57
Diet Carnation Instant Breakfast (DIB) w/8oz Whole, Low fat, Skim with Ice Cream 1 packet DIB with 8oz milk 38
Diet Carnation Instant Breakfast (DIB) w/8oz Whole, Low fat, Skim 1 packet DIB with 8oz milk 20
Coffee/Decaf Tea/Decaf Tea 0
Cranberry Juice 4 oz (1/2c) 17
Custard 4oz (1/2 c) 19
Diet Custard ½ cup 9
Diet Jello ½ c 2
Diet Jelly 1 Tble 6
Ensure Plus 8 oz (1c) 50
Ginger ale 8 oz 25
Diet Ginger ale 0
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SC ProtocolNutrition

• ? When do trays arrive on your unit?
• ? How will you know ?
• ? Which patients require insulin ?
• ? Entire meal?
• ? Insulin based of CHO consumed
• ? Plan to follow up on CHO consumed?
• ? Partnership
• Patient, Nurse, CNA, Nutrition

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RD role in team approach developing protocols

• Representative from nutrition department,
• Resource for PO, TF, and TPN protocol development
• Education
• Support for post implementation follow up
  evaluation

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Implementation of Protocols

• Support staff (nutrition) need to be available
  for RN and MD questions
• Nutrition staff evaluating appropriateness of
  diet ordering- RD to notify MD if change in diet
  is needed
• Nutrition staff available on patient care unit at
  meal times

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Points of discussion

• Support
• Champion physician and administration
• Room service vs. Scheduled tray delivery
• Appropriateness of diet orders
• Nursing time constraints at meals
• Can nutrition assist?
• Resources for implementation
• Budget, staffing
• Emphasis on inter-department communication
• Work on most common scenarios
• (i.e. TF protocols- cant make protocols for
  every scenario)

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Research Nutrition Role in Education to Nursing
Staff

• Carbohydrate counting education to nursing in
  preparation for implementation of an insulin
  protocol
• Kate Hawley RD, LD and Sharon Tate MS, RD, LD
• Evaluate education provided by dietitians to
  nursing staff in preparation for the
  implementation of new insulin protocols.
• Future topics

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Breakout Session

• What is your facility currently practicing for
  glycemic control at meal times?
• How would you improve prandial glycemic control
  at your hospital?

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Thank You for the opportunity for us to share our
program we hope it inspires you to evaluate
yours. THOUGHTS, OPINIONS AND QUESTIONS ???