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/clinical/cckm-tools/content/order-sets/inpatient/hospital-wide/name-98194-en.cckm

201706160

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,Hospital-wide

ED/IP – Diabetes Management with Pump – Adult – Supplemental [3139]

ED/IP – Diabetes Management with Pump – Adult – Supplemental [3139] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


ED/IP - Diabetes Management With Pump - Adult - Supplemental [3139]
Intended for Adult Patients Only
Patient Care Orders
Nutrition [30245]
Diabetes Meal Plan [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: Diet Modifications
Diet Modifications: Diabetes
Bedside Meal Instructions:
Room Service Class:
Non-Categorized Patient Care Orders [97411]
Glucose, POC [IPGLUCOSE] BEFORE MEALS AND BEDTIME, Starting today,
Routine, Glucose, POC should always be ordered in
conjunction with orders for hypoglycemia
management and monitoring as indicated in the
Hypoglycemia Management (Adult) panel.
If Conditional, What Condition?
Glucose, POC [IPGLUCOSE] EVERY 6 HRS IF NPO/ CONT. TUBE FEEDING/ OR
TPN, Starting today, Routine, Glucose, POC should
always be ordered in conjunction with orders for
hypoglycemia management and monitoring as
indicated in the Hypoglycemia Management (Adult)
panel.
If Conditional, What Condition?
Glucose, POC [IPGLUCOSE] CONDITIONAL - RN COLLECT, Starting today,
Routine, Glucose, POC should always be ordered in
conjunction with orders for hypoglycemia
management and monitoring as indicated in the
Hypoglycemia Management (Adult) panel.
If Conditional, What Condition? 30 minutes before
start of cyclic tube feeding and 6 hours after initiation
Glucose, POC [IPGLUCOSE] SUPPLEMENTAL CHECK AT 0200, Starting today,
Routine, Glucose, POC should always be ordered in
conjunction with orders for hypoglycemia
management and monitoring as indicated in the
Hypoglycemia Management (Adult) panel.
If Conditional, What Condition?
Medications - Continuous Subcutaneous Insulin Infusion
Continuous Subcutaneous Insulin Infusion [30289]
UWHC Agreement to Use Patient's Own
Medication Delivery Device
URL: https://uconnect.wisc.edu/clinical/tools-
resources/med-
records/consentsagreements/resources/name-
36522-en.file
Patient/caregiver to change Insulin pump
catheter every 2-3 days or per home regimen
[NURVAD0053]
CONTINUOUS, Starting today
Page 1 of 8
Printed by SPENCER, LINDSEY M [LMS033] at 6/8/2017 5:50:33 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Insulin pump subcutaneous patient's own
[950042]
4 X DAILY (NOTE ACKNOWLEDGE)
Patient may use own insulin and pump to self
administer insulin. The attached "Agreement to Use
Medication Delivery Device (301503-DT)” form
MUST be completed with every admission.
Document all boluses and daily doses on IV/IV MAR.
Document carbohydrate grams eaten in Doc
Flowsheet.
Subcutaneous pump insulin type:
{aspart;lispro:2000130}
Basal rate:
Starting at midnight give at *** units/hr.
{Subsequent rate changes:2000131}
Insulin-to-carbohydrate ratio:
Starting at midnight give 1 unit of insulin per *** g of
carbohydrate
{Subsequent insulin to carbohydrate ratio
changes:2000132}
Target blood glucose goal *** mg/dL.
{Subsequent target glucose:2000442}
Active insulin *** hours.
Sensitivity (correction factor):
Starting at midnight give 1 unit of insulin for every ***
mg/dL above glucose goal.
{Subsequent sensitivity settings:2000133}
Subcutaneous Insulin Pump (patient's own)
Documentation Requirements [NURCOM0022]
SEE COMMENTS, The nurse must document the
following in the IV/IV MAR or MAR:
1) Once Daily on day shift: Total Daily Dose (TDD)
administered from the previous day. (This is the total
amount administered in 24 hours. The patient should
be able to retrieve this amount from the "Utilities" or
"History" menu or "Home/My records" section
depending on the brand of pump.)
2) All bolus doses given by the patient for meal
coverage and/or for correction of hyperglycemia.
3) Document carbohydrate grams eaten in Doc
Flowsheet.
"Agreement to Use Medication Delivery Device
(301503-DT)" form MUST be completed with every
admission.
Note: Self Administered Medication Program
Documentation [950000]
ONCE
Nursing Communication - Catheter:
Subcutaneous Insulin Pump (Patient's Own)
[NURVAD0053]
SEE COMMENTS, Add Lines/Drains/Airway (LDA) for
Catheter: Subcutaneous Insulin Pump (Patient's
Own).
Document site condition twice daily and PRN.
Document site change as often as needed (usually
every 2-3 days)
Page 2 of 8
Printed by SPENCER, LINDSEY M [LMS033] at 6/8/2017 5:50:33 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Nursing Communication - Insulin Pump
Competency Documentation [NURCOM0022]
ONCE For 1 Occurrences, Complete documentation
of insulin pump self-administration competency when
pump orders given. Update if competency changes.
Chart within Patient Education activity using Title:
Diabetes, Therapeutic Regimen Management,
Ineffective, Topic: Insulin Pump (Patient's Own).
Medications - Hypoglycemia Treatment
Hypoglycemia Management [123771]
URL:
Hypoglycemia Management (Adult) [191576]
Adult Hypoglycemia Treatment Algorithm URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/diabetes-and-
endocrinology/related/name-97511-en.cckm
Glucose, POC [IPGLUCOSE] AS NEEDED FOR SIGNS AND SYMPTOMS OF
HYPOGLYCEMIA, Starting today For Until
specified, Routine, Glucose, POC should always be
ordered in conjunction with orders for hypoglycemia
management and monitoring as indicated in the
Hypoglycemia Management (Adult) panel.
If Conditional, What Condition?
Glucose, POC [IPGLUCOSE] AFTER PROVIDING HYPOGLYCEMIA
TREATMENT, Starting today For Until specified,
Routine, Glucose, POC should always be ordered
in conjunction with orders for hypoglycemia
management and monitoring as indicated in the
Hypoglycemia Management (Adult) panel.
If Conditional, What Condition?
Per hypoglycemia treatment algorithm Recheck
glucose 15 minutes after providing treatment until
glucose is greater than or equal to 70 mg/dL. If
patient has been critically low (i.e., glucose less
than 40 mg/dL), recheck glucose after 1 hour to
ensure glucose remains greater than or equal to
70mg/dL. After resolution of mild hypoglycemia
(i.e., glucose 40-69 mg/dL), consider rechecking
after 1 hour if patient has signs/symptoms of
hypoglycemia or is at risk for a subsequent
hypoglycemic event (e.g., previously administered
insulin still active, altered renal status, altered
mental status, NPO or interrupted nutrition, or any
other condition that increases hypoglycemia risk)
Notify Provider [NURCOM0001] Provider to Notify: Provider
Notify based on: Blood Glucose,Other
If blood glucose > (mg/dL): 400
If blood glucose < (mg/dL): 40
Other: Nutritional status changes
Hypoglycemia Treatment for blood glucose less
than 40 mg/dL and patient able to eat/swallow
safely [NURCOM0022]
CONDITIONAL, Starting today For Until specified
If Conditional, What Condition? If blood glucose
less than 40mg/dL and patient able to eat/swallow
safely.
Give 30 grams of carbohydrate (8 oz. of fruit juice).
Repeat treatment until glucose is 70 mg/dL or
greater.
Page 3 of 8
Printed by SPENCER, LINDSEY M [LMS033] at 6/8/2017 5:50:33 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Hypoglycemia Treatment for blood glucose
between 40 to 69 mg/dL and patient able to
eat/swallow safely [NURCOM0022]
CONDITIONAL, Starting today For Until specified
If Conditional, What Condition? If glucose is 40-69
mg/dL and patient able to eat/swallow safely
Give 15 grams of carbohydrate (4 oz of fruit juice).
Repeat treatment until glucose is 70 mg/dL or
greater.
glucose-vitamin C chew tab [50690] 16 g, Oral, EVERY 15 MINUTES PRN,
hypoglycemia, Hypoglycemia, For blood glucose
40-69 mg/dL
Use in patients able to safely eat/swallow but
unable to tolerate volume of fruit juice or per patient
preference. Repeat every 15 minutes until blood
glucose is 70 mg/dL or greater.
glucose-vitamin C chew tab [50690] 32 g, Oral, EVERY 15 MINUTES PRN,
hypoglycemia, Hypoglycemia, For blood glucose
less than 40 mg/dL
Use in patients able to safely eat/swallow but
unable to tolerate volume of fruit juice or per patient
preference. Repeat every 15 minutes until blood
glucose is 70 mg/dL or greater.
glucagon injection kit [107799] 1 mg, Subcutaneous, PRN, For blood glucose less
than 69 mg/dL and patient unable to eat/swallow
safely AND has NO IV access
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia
Algorithm
dextrose injection [800233] 12.5 g, Intravenous, PRN, For blood glucose 40-69
mg/dL and patient unable to eat/swallow safely
AND has IV access
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia
Algorithm
dextrose injection [800233] 25 g, Intravenous, PRN, For blood glucose less
than 40 mg/dL and patient unable to eat/swallow
safely AND has IV access.
Repeat every 15 minutes until blood glucose is 70
mg/dL or greater. See Adult Hypoglycemia
Algorithm
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL - RN COLLECT, Starting today For
7 Days, STAT
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Draw if blood
glucose is less than 40 mg/dL or greater than 400
mg/dL.
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL - RN COLLECT, Starting 6/16/17
For 7 Days, STAT
If add on test, what should lab do if unable to add
test to previous specimen?
If Conditional, What Condition? Draw if blood
glucose is less than 40 mg/dL or greater than 400
mg/dL.
Laboratory
Obtain If Not Done Within Last 90 Days [143671]
Page 4 of 8
Printed by SPENCER, LINDSEY M [LMS033] at 6/8/2017 5:50:33 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

HEMOGLOBIN A1C [HA1C] NEXT AM, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Consults
Consults [19218]
Diabetes Consult Order Panel (Adult) [208750]
Diabetes Management Service : Will provide management or treatment recommendations for
patients with hyperglycemia and/or those who report outpatient use of insulin or other diabetes
medications. Patients should be expected to remain inpatient > 24 hrs from time of consult.
Consult is required for patients with insulin pumps or who use U-500 insulin. Consult Endocrine
for any non-diabetes-related endocrine questions.
Learning Center - Diabetes Education (Adult): Diabetes Education (Adult): Diabetes education
(meter/insulin skills/other diabetes survival skills) for patients/families with knowledge deficits
and/or need for diabetes knowledge assessment. Recommended for all new diagnoses or
patients with A1C > 9.
Diabetes Education – Nutrition: Diabetes nutrition therapy including nutrition assessment,
carbohydrate education (consistent carbohydrate meals, use of insulin-to-carbohydrate ratio),
and/or individualized, nutritious meal planning for carbohydrates, portions, or considering other
comorbidities. Recommended for all new diagnoses or patients with A1C > 9
Consult Diabetes Management Service (DMS)
(Inpatient) [CON0022]
ONCE
Can this consult be done via video?
Call back number:
Intent: Consult and Recommend (Write Orders)
Concern or Specific Question or Task to be
Addressed (Symptom, Sign, or Diagnosis):
Consult Learning Center - Diabetes Education
(Adult) [CON0021]
ONCE, Routine, - If patient is newly diagnosed or is
new to insulin, provide 24 hours notice to allow
adequate time for education,
- Indicate diabetes medication/treatment plan if
known.
- Consults requested after 1600 on Fridays may not
be seen until following Monday. Learning Center
available Mon-Sat 0800-1630 (only 1 RN available
on Saturday for CSC and AFCH).
- Staff may be contacted by Pager 7927 on
weekdays and Pager 3276 on weekends.
- Learning Center staff are not available on
holidays.
Type of Education: Diabetes Self-Management
Education
Reason For Consult:
Expected Discharge Date:
Diabetes management / treatment plan:
Can this consult be done via video?
Page 5 of 8
Printed by SPENCER, LINDSEY M [LMS033] at 6/8/2017 5:50:33 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Consult Diabetes Education - Nutrition (Inpatient)
[CON0126]
ONCE, Routine, · If your patient is newly
diagnosed and/or is new to insulin therapy, provide
24 hours notice to allow adequate time for nutrition
education.
· Indicate diabetes medication/treatment plan if
known.
· Consults requested after 1300 on Friday may not
be completed until the following Monday.
· If you are placing a consult on a weekend day for
a patient who will be discharging that weekend,
please have the Paging Center contact the on-call
dietitian to help you facilitate the diabetes nutrition
education session prior to the patient's discharge.
Type of Education: Diabetes Self-Management
Education
Reason For Consult:
Expected Discharge Date:
Diabetes management / treatment plan:
Can this consult be done via video?
Follow-up Appointments - Required Documentation
Schedule Appointment - Diabetes Follow-up [149023]
Schedule Appointment with Provider to Manage
Diabetes [NURCOM0026]
Reason for Hospital Follow Up Appointment: Diabetes
management
Which Provider: Patient's Specific PCP/Care Team
When do you want appointment:
Which Clinic or Specialty:
Follow Up Appointments - Diabetes (Single Response) [149021]
Joint Commission Requirement: Patients must have an appointment scheduled WITHIN 30
DAYS of discharge with a provider who will manage their diabetes care. Exclusions are allowed
based upon patient situation (e.g., discharge to skilled nursing facility, patient refusal, etc.).
Schedule Appointment with Provider to Manage
Diabetes [222085]
Schedule Appointment [NURCOM0026] Reason for Hospital Follow Up Appointment:
Diabetes management
Which Provider:
Appointment scheduled (with provider who can
manage diabetes) [COR0064]
ONCE For 1 Occurrences, Routine
Documentation (required): Appointment scheduled
(with provider who can manage diabetes)
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge
with a provider who will manage a patient's
diabetes care (e.g., primary care physician,
endocrinologist, etc.) is a Joint Commission
requirement. Exclusions are allowed based upon
patient situation (e.g., patient discharging to a
skilled nursing facility, patient refusal, etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed
to request assistance in scheduling an
appointment.
Page 6 of 8
Printed by SPENCER, LINDSEY M [LMS033] at 6/8/2017 5:50:33 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Appointment scheduled per patient report
(ENTER DATE IN COMMENTS) [COR0064]
ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): Appointment scheduled
per patient report (ENTER DATE)
Date of appointment (Month/Year):
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is
a Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Appointment pending: patient discharged on
weekend; follow-up information provided
[COR0064]
ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): Appointment pending:
patient discharged on weekend; follow-up information
provided
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is
a Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Free clinic information provided [COR0064] ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): Free clinic information
provided
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is
a Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Page 7 of 8
Printed by SPENCER, LINDSEY M [LMS033] at 6/8/2017 5:50:33 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

No appointment: Patient discharging to a facility
(e.g., skilled nursing facility, correctional facility,
etc.) [COR0064]
ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): No appointment: Patient
discharging to a facility (e.g., skilled nursing facility,
correctional facility, etc.)
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is
a Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
No appointment: Patient refusal [COR0064] ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): No appointment: Patient
refusal
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is
a Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
No appointment: Patient does not have diabetes
[COR0064]
ONCE, Starting today For 1 Occurrences, Routine
Documentation (required): No appointment: Patient
does not have diabetes
1. This order facilitates documentation (only) about
follow-up appointments for patients with diabetes.
2. Scheduling an appointment before discharge with a
provider who will manage a patient's diabetes care
(e.g., primary care physician, endocrinologist, etc.) is
a Joint Commission requirement. Exclusions are
allowed based upon patient situation (e.g., patient
discharging to a skilled nursing facility, patient refusal,
etc.)
3. Only select "Appointment Scheduled" if an
appointment has already been scheduled with a
provider who can manage patient's diabetes.
4. Use the Schedule Appointment order as needed to
request assistance in scheduling an appointment.
Page 8 of 8
Printed by SPENCER, LINDSEY M [LMS033] at 6/8/2017 5:50:33 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org