A telehealth case management program’s use of a diabetes insulin adjustment protocol works well with technology to keep data fresh, and a commitment to assessing and adjusting as needed, according to protocol administrators.

Nurses can review blood glucose data as it comes in, assessing for trends, says Nancy Brown, MSN, ARNP, ANP-BC, advanced registered nurse practitioner at Mann-Grandstaff VA Medical Center in Spokane, WA.

Diabetic patients who are eligible for the protocol use technology to send their blood glucose numbers to vendors that contract with the Veterans Health Administration, says Barbara Carrara, MSN, RN, home telehealth case manager at Mann-Grandstaff VA Medical Center.

The data is analyzed for averages and trends. “For example, I have a patient in front of me and I can see all of his blood sugar ratings for the past 14 days, and I can go back 180 days,” Carrara says. “This real-time data coming in through the vendor website is so important because when you’re making insulin adjustments, you’re making them based on patterns over time, and it makes the outcome much safer.”

Nurses always have the patient’s blood glucose data available before they begin the telehealth call with the patient, Carrara adds.

“We don’t even call the patient until we see their numbers,” she says. “Another real advantage to going to the system we use is if there’s something wrong, like an extreme high or a low number, we can react in real time to that.”

As the protocol was developed, Brown’s goal was to keep it simple and easy to follow. After testing, she found that it also had to be very specific.

“You couldn’t do a range order, saying, ‘If the blood sugar is greater than 200 for X amount of days,’ you could not say, ‘Adjust by 2 to 4,’” Brown says. “You had to be specific.”

The Joint Commission, the health system’s accrediting body, does not allow range orders because of the potential for errors or adverse outcomes, Carrara notes.

After a year of using the protocol, they decided it may be too restrictive: “Nurses’ hands were tied in certain instances, such as when a patient had low blood sugar or multiple low blood sugars,” Brown explains.

Providers gave patients a sliding scale for bolus insulin adjustment, and they changed the sliding scale to a PRN mealtime insulin chart. It instructs patients that their fast-acting insulin is married to the meal and is not to be used every four hours, Brown says.

“This seemed to work when bolus insulin was first added, but we still needed something for when a patient was already on a set dose of bolus insulin,” she says.

The solution was a corrective chart that patients could use to add or subtract to their set mealtime dose, according to their pre-meal blood glucose level. “Initially, orders were written that patients may use the PRN mealtime chart or the corrective chart,” Brown says.

“The RNs learned to look at patterns and the basal-bolus ratio,” she adds. “This was taken into account when writing the protocol.”

One of the more interesting periods was when the protocol was suspended briefly as it was being adjusted, and case managers found they missed it, says Freta L. Leddige, BSN, RN, nurse manager for home telehealth at Mann-Grandstaff VA Medical Center.

“We stopped it for a short time and we nearly went crazy,” Leddige says.