/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/order-sets/,/clinical/cckm-tools/content/order-sets/inpatient/,/clinical/cckm-tools/content/order-sets/inpatient/hospital-wide/,

/clinical/cckm-tools/content/order-sets/inpatient/hospital-wide/name-98216-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 - Insulin Infusion - Adult - Supplemental [1345]

eD/IP - Insulin Infusion - Adult - Supplemental [1345] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


ED/IP - Insulin Infusion - Adult - Supplemental [1345]
for Adult Patients OnlyIntended
Patient Care Orders
Non-Categorized Patient Care Orders [143638]
Glucose, POC [IPGLUCOSE] SEE COMMENTS, Starting today For 7 Days,
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?
Every hour until within target range of 110-150 mg/dL
for 3 hours (3 readings in a row), then decrease
frequency to every 2 hours. Hourly monitoring must
be resumed if blood glucose deviates from target
range.
After Priming IV Tubing with Insulin, Waste 20
mL Insulin Drip to Saturate all IV Tubing Binding
Sites [NURVAD0053]
CONTINUOUS, Starting today
B4/5 Protocol [112874]
orders"Protocol/Policy WITHOUT Cosign" order mode when signing these Use
Cardiovascular Surgery Insulin Infusion Protocol
Has Been Initiated [NURMON0063]
CONTINUOUS, Routine
Contingency Parameters [112155]
Notify Provider - Insulin Infusion [NURCOM0001] Provider to Notify: Provider
Notify based on: Other
Other: Hypoglycemia has not resolved within 30
minutes of Insulin Infusion Algorithm hypoglycemia
treatment orders,Infusion rate is less than 1 unit/hour
with glucose values less than Target Range,ICUs
only: When patient initially meets critieria to move to
columns 7-9,If patient transferring from ICU to
general/IMC care and still requiring high dose
columns 7-9
Medications
Insulin Drip [18803]
Wisconsin Insulin Infusion HIGH Dose-Adult-
Practice Protocol (ICU only)
URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/delegationpractice-
protocols/practice-protocols/related/name-97441-
en.cckm
Wisconsin Insulin Infusion Standard Dose-Adult-
Practice Protocol
URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/delegationpractice-
protocols/practice-protocols/related/name-97442-
en.cckm
Note: Discontinue all previous insulin orders and
oral hypoglycemic agents [950018]
ONCE For 1 Doses
insulin regular (human) infusion [700217] 0.2-30 Units/hr, Intravenous, CONTINUOUS
Administer insulin drip in accordance with Insulin
Infusion Algorithm - Adult. (General care and IMC
units - use standard algorithm columns 1-6; ICU only -
use standard and HIGH DOSE columns 1-9)
Insulin Drip [112327]
Wisconsin Insulin Infusion HIGH Dose-Adult-
Practice Protocol (ICU only)
URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/delegationpractice-
Page 1 of 7
Printed by SPENCER, LINDSEY M [LMS033] at 6/8/2017 5:46:59 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

protocols/practice-protocols/related/name-97441-
en.cckm
Wisconsin Insulin Infusion Standard Dose- Adult -
Practice Protocol
URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/delegationpractice-
protocols/practice-protocols/related/name-97442-
en.cckm
Note: Discontinue all previous insulin orders and
oral hypoglycemic agents [950018]
ONCE For 1 Doses
insulin regular (human) infusion [700217] 0.2-54 Units/hr, Intravenous, CONTINUOUS
Administer insulin drip in accordance with Insulin
Infusion Algorithm - Adult. (General care and IMC
units - use standard algorithm columns 1-6; ICU only -
use standard and HIGH DOSE columns 1-9)
Nutritional Insulin (Single Response) [145568]
Insulin Lispro with Insulin to Carbohydrate Ratio
(Carb Counting) [129171]
Select Insulin to Carbohydrate Ratio (ICR)
STEP 1: Calculate the patient’s Total Daily Dose
STEP 2: Select corresponding ICR. (Enter Admin Instructions below)
STEP 3: Adjust ICR if glucoses remain >180 mg/dL.
Other Considerations:
• A custom ICR may be entered for pts with established regimen at home.
• RENAL INSUFFICIENCY/FAILURE: select a higher ratio to decrease hypoglycemia risk (e.g.,
if patient’s TDD is 40 units increase the ICR from 1:12 to 1:15
• BASAL INSULIN ONLY PTA (dose >/=40 units/day): select corresponding ICR using chart
above; then reduce basal dose by 25-50%.
Insulin to Carbohydrate Ratios- Adult (ICRs) URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/diabetes-and-
endocrinology/related/name-97513-en.cckm
insulin lispro (human) (HUMALOG) 100 UNIT/ML
injection [53264]
0-30, Subcutaneous, 3 X DAILY (AT MEALTIME)
Insulin to Carbohydrate Ratio (ICR) {RXR INSULIN
TO CARBOHYDRATE RATIO (ICR):2000496}
Document carbohydrate grams eaten in Doc
Flowsheet.
Measure Carbohydrate Intake [NURDIE0016] CONTINUOUS, Routine, Document carbohydrate
grams eaten in Doc Flowsheet
insulin lispro - Note: Snack carbohydrate
counting dose [53264]
0-30, Subcutaneous, PRN, For snacks > 30 g
Insulin to Carbohydrate Ratio (ICR) {RXR INSULIN
TO CARBOHYDRATE RATIO (ICR):2000496}
Document carbohydrate grams eaten in Doc
Flowsheet
insulin lispro (human) (HUMALOG) 100 UNIT/ML
injection [53264]
4 units, Subcutaneous, 3 X DAILY (AT MEALTIME)
Hold dose if patient NPO. Give half dose if patient
eating <50% of meal. Give within 15 minutes of meal
Total Daily Dose (TDD)
(total amount of scheduled basal
and nutritional insulin doses in 24
hours)
Insulin to Carbohydrate Ratio
(ICR) (1 unit insulin covers ____
grams of carbohydrate)
15 - 29 units 1 unit:20 grams
30 – 39 units 1 unit:15 grams
40 – 49 units 1 unit:12 grams
50 – 59 units 1 unit:10 grams
60 - 89 units 1 unit:8 grams
90-119 units 1 unit:5 grams
> 120 units 1 unit: 4 grams
Page 2 of 7
Printed by SPENCER, LINDSEY M [LMS033] at 6/8/2017 5:46:59 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Nutritional Insulin [154492]
insulin lispro (human) (HUMALOG) 100 UNIT/ML
injection [53264]
4 units, Subcutaneous, 3 X DAILY (AT MEALTIME)
Hold dose if patient NPO. Give half dose if patient
eating <50% of meal. Give within 15 minutes of meal
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.
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.
Page 3 of 7
Printed by SPENCER, LINDSEY M [LMS033] at 6/8/2017 5:46:59 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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.
Consults
Consults [17940]
Diabetes Consult Order Panel (Adult) [208741]
Page 4 of 7
Printed by SPENCER, LINDSEY M [LMS033] at 6/8/2017 5:46:59 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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 7
Printed by SPENCER, LINDSEY M [LMS033] at 6/8/2017 5:46:59 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?
Consults [104225]
Diabetes Consult Order Panel (Adult) [188497]
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):
Page 6 of 7
Printed by SPENCER, LINDSEY M [LMS033] at 6/8/2017 5:46:59 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

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?
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?
Page 7 of 7
Printed by SPENCER, LINDSEY M [LMS033] at 6/8/2017 5:46:59 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org