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Mastering the Meal Triad: Best Practices & Implementation Strategies


Kerri Doucette MSN, RN, RDN, CDCES, MSNS | Glytec


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[00:00:00] Kerri Doucette: Good afternoon everyone. I'm so happy you're able to join us today. The focus of the presentation is to review best practices related to the meal triad process and to provide you with some actionable ideas of how you can implement changes in your organization to drive safe insulin practices. I know this is a hot topic for many of our customers and many of you in the audience.


[00:00:28] Kerri Doucette: If you have any questions at any point during today's session, add those to the q and a function on your screen and we'll get back to you with answers. My name is Kerri Doucette, a Senior Clinical Customer Success Manager at Glytec. I'm a nurse, dietician and a certified diabetes care and education specialist.


[00:00:47] Kerri Doucette: My career has been dedicated to advocating for individuals with diabetes. My years of experience leading both inpatient and ambulatory diabetes initiative has allowed me the opportunity to focus on strategic, transformative, and innovative diabetes redesign initiatives to drive change for better outcomes.


[00:01:08] Kerri Doucette: The meal triad became an interest of mine when I was working as an inpatient diabetes educator and observed limited standardization and poor communication around this work. It wasn't on anyone's radar that a poorly timed meal triad could potentially be causing harm in the form of hospital acquired hypo and hyperglycemia.


[00:01:30] Kerri Doucette: Okay, so let's kick off today's session by hearing from you. I have some questions teed up here to get an opportunity to hear, um, your work practices regarding the meal triad. So please go ahead and throw your answers in the chat. And again, if you have any questions, I'll reach out to you after the. All right, so the first question at your hospital, when is mealtime prandial insulin administered? A usually given to patients before the patient starts eating.


[00:02:02] Kerri Doucette: B, usually given to patients after the meal is finished. C, My hospital uses correction insulin only, mealtime bolus coverage is not administered or D. Other.  In August, I presented on this topic at ADCES 2022. The audience responses were varied around this workflow correction only. Insulin administration was still common.


[00:02:28] Kerri Doucette: Most of the responses indicated that if mealtime insulin was given, it was administered after the meal. And I'm interested to hear your responses today. Next question, Please take a moment and answer yes or no in the chat.  If your hospital doses prandial insulin, do nurses at your hospital count carbohydrates to determine a mealtime insulin dose?


[00:02:53] Kerri Doucette: Again, at ADCES, the answers varied. If your hospital carb counts for prial insulin dosing, The Endocrine Society recommend developing a safe or a policy for safe implementation expertise, Resources and training are needed for hospitals at carb. Insulin dosing technology may be able to provide adjustments to the insulin to carb ratio in the hospital setting.


[00:03:20] Kerri Doucette: Our final question, when does your hospital deliver meals? A, at scheduled times for each unit. B. When a patient requests a meal, “room service” style. C. Both. or D. Other.  Many food service departments have been advocating for room service delivery model to drive up patient satisfaction scores based on the feedback we received from diabetes educators across the country.


[00:03:52] Kerri Doucette: It appears though that many hospitals that move to this model are switching back to scheduled mealtime delivery, especially for patients with diabetes. We know this is a challenge based on the responses we received and the literature support scheduled mealtimes versus the meals on demand for patients with diabetes.


[00:04:11] Kerri Doucette: All right, so now it's time for a quiz, and I'm gonna give you a big hint. The answer is D. So when we're talking about the hospital meal triad today, we are talking about a workflow that impacts the breakfast, lunch, and dinner workflow. It is the timely coordination of blood glucose monitoring, meal consumption, and mealtime insulin administration.


[00:04:36] Kerri Doucette: And it should be completed within 30 to 45 minutes. So this is a common scenario that you may be familiar with. Um, the patient care technician checks a blood glucose at 7:30 in the morning. The patient receives breakfast at around 9 or 9:15 and finishes eating around 9:40. The nurse comes in and, um, doses the mealtime correction insulin around 10:00, which is based on a blood glucose taken at 7:30.


[00:05:05] Kerri Doucette: Then the lunch blood glucose is taken at 11:30. The patient eats at 12 and the insulin is given at 12:15. So why is this a problem? Blood glucose, um, and the meal consumption and the insulin timing are all mismatched, which can lead to the patient harm. In this scenario. The blood glucose for correction insulin is two and a half hours old, and the mealtime bolus is insulin is given about an hour after the patient started the meal lunch.


[00:05:37] Kerri Doucette: The lunch blood glucose is taken only an hour and a half after the breakfast insulin was administer. And is likely elevated due to the postprandial glucose excursion. The patient may receive additional correction insulin for this postprandial blood glucose elevation, putting the patient at risk for insulin stacking in hypoglycemia since the breakfast and lunch doses were administered so close together.


[00:06:01] Kerri Doucette: So what does the literature say about insulin therapy in the hospital setting? About one third of all hospitalized patients have diabetes and 40 to 50% of all hospitalized patients experience hyperglycemia requiring insulin management. Insulin is classified as a high-volume, high-risk medication that can result in medication administration errors that cause serious clinical outcomes for patients, including death.


[00:06:30] Kerri Doucette: These errors include poor insulin timing and incorrect dosing. However, these adverse events are preventable. The American Diabetes Association and, uh, the American Association of Clinical Endocrinologists voice in a consensus statement that a preferred approach to achieving glycemic control in the hospital is with IV insulin in critical care in basal, prandial and correction, subcutaneous insulin and non ICU.


[00:07:01] Kerri Doucette: The 2022 Standards of Medical Care and Diabetes continues to state that insulin therapy should be initiated for persistent hyperglycemia starting at a threshold of greater than or equal to 180 milligrams per deciliter, and that an insulin regimen with basal, prandial and correction insulin is the preferred treatment for noncritically ill patients with good nutrition intake. It is still strongly discouraged for sliding scale only for most patients.


[00:07:27] Kerri Doucette: Again, insulin is a high alert medication that can lead to serious safety events related to hypoglycemia, due to errors of medication administration potentially causing serious consequences in patient harm. And it's linked to altered mental status coma, and death.


[00:07:52] Kerri Doucette: Inpatient hyperglycemia may contribute to impaired immune function and inflammation. Cardiovascular complications and and poor outcomes. Both hypo and hyperglycemia contribute to increased length of stay in the hospital, increased workload on the staff, and increased costs. Healthcare staff are key influencers of safe practice of insulin and administration in the hospital.


[00:08:20] Kerri Doucette: The impact of harm to patients negatively affects the patient as well as the healthcare team and the hospital system. By collaborating with the healthcare team that participates in the meal triad, process gaps can be identified and process improvements can be made.


[00:08:42] Kerri Doucette: So let's recap what we know about, um, inpatient glycemic management. We know that rapid acting insulin is designed to closely mimic normal physiologic insulin action. And that rapid acting insulin typically starts to be effective within 15 minutes, and that prandial insulin should be administered within 15 minutes before the start of the meal or up to 30 minutes after the start of the meal.


[00:09:03] Kerri Doucette: Really, depending on the insulin analogue used and the patient's status, a point of care blood glucose should be obtained at the start of the meal, prior to the patient eating and not greater than 30 minutes prior to correction insulin administration. As mentioned, a poorly timed meal triad has been associated with hospital acquired hypo and hyperglycemia.


[00:09:29] Kerri Doucette: But the good news is that studies have demonstrated that improved glycemic control with coordination, um, can occur with improved coordination of blood glucose monitoring, insulin administration, and nutrition consumption. So here is the goal. Obtain the blood glucose. Deliver the tray, have the patient consume the meal and administer insulin within 30 to 45 minutes.


[00:09:52] Kerri Doucette: So we discussed the best practices and the importance of this safe timing, but why is it so challenging to accomplish this in the hospital setting? And feel free to enter your own challenges into the chat. The literature describes staffing shortages, conflicting nursing priorities, and inconsistent meal delivery schedule.


[00:10:15] Kerri Doucette: Lack of communication among dietary and nursing staff, and sometimes patients start eating before the blood glucose is checked. Some other challenges that were mentioned at ADCES where that patients will go off the unit after the blood glucose is checked and when he or she returns, the patient starts eating before another blood glucose can be checked.


[00:10:35] Kerri Doucette: Many patients eat two meals within a 2-3 hour period. Visitors, um, bringing food to the patient from home, which can, um, the nurses aren't aware of. So what is the solution and how do you even begin to improve the meal triad workflow? We're gonna spend the next few minutes discussing how to develop a meal triad quality improvement initiative, and develop an audit tool that may be helpful, and identifying gaps in prioritizing areas of focus.


[00:11:04] Kerri Doucette: The steps on this slide can be completed in an order that works best for your organization. The first step here is to develop a team. Team members may include nursing and dietary leadership, a diabetes educator pharmacy, and a patient care nurse. Interprofessional team collaboration brings a diversity of ideas and multi-departmental buy-in for implementing new processes.


[00:11:30] Kerri Doucette: Healthy communication among the team is a key factor in successful implementation of process improvement initiative. Next, review your data and be clear about why you are seeking to make a change. Is your organization struggling with elevated hyper and hypoglycemia rates with patients on SubQ insulin regimens, and you wanna improve outcome metrics?


[00:11:52] Kerri Doucette: Or has a serious safety event occurred around insulin administration and you are tasked with looking deeper into potential causes? Take an opportunity to walk the process. Have team members start observing in the kitchen where the trays are getting prepped, and observe the workflow from the kitchen to meal delivery at the patient bedside.


[00:12:16] Kerri Doucette: Observe when and who is checking the point of care blood glucoses, and how are results being communicated? Observe when the nurses are administering insulin. Notice when the tray is getting picked up. Have carbohydrates been counted? Sites who dose prandial insulin based on the amount of carbs consumed by mapping out the current process to identify gaps in the workflow.


[00:12:43] Kerri Doucette: Conducting audits or surveys may be useful when trying to identify root causes. A general aim statement may help get the process started based on the opportunities that have been identified. So an example of this could be, “Our nursing staff will reduce the duration of point of care blood glucose insulin administration from 90 minutes to less than 45 minutes within three months.”


[00:13:11] Kerri Doucette: In this statement, be sure to include what, how much, whom, and by when. Input the identified causes of hypoglycemia into a Pareto chart to highlight the most common. This aids in identifying high priority focuses and may help to identify areas to focus on first based on effort and impact. It may seem overwhelming when you start to discover how many factors are negatively impacting your goal, but you don't have to boil the ocean and fix everything.


[00:13:44] Kerri Doucette: By identifying the main root causes, you may be able to make minimal changes to your current state for changes that are significant enough to develop a huge impact moving you closer to your goal. Process metrics drive outcome metrics. Process metrics should be developed and monitored to ensure the new process is working as planned and to ensure continued compliance with the process.


[00:14:11] Kerri Doucette: Once you complete these steps, map out a new process map. Provide training to all team members who will be impacted by the change. This may include dietary staff, patient care technicians, and nurses. In some cases, a pilot in a specific area or a specific population may be desirable Before implementing the plan across multiple units for the system, consider methods to address changes or potential resistance or barriers to change, such as appreciative inquiry, SWAT analysis for the stages of change.


[00:14:49] Kerri Doucette: Finally, implement the new process. Evaluate effectiveness and make necessary tweaks quickly. Once your process is in place, develop a policy to help ensure acceptance and adherence to the new process. Based on the literature and from working with sites who have actively engaged in this process, there are five best practice areas I would like to highlight.


[00:15:12] Kerri Doucette: First is the meal delivery. So we've already talked about having standard delivery. But also having a notification of when those trays are going to be delivered. It's helpful maybe if the kitchen calls up to the unit and says that the trays are on the way and an alert goes out to the nursing text as well as the nurses to be aware that now is the time to check the blood sugar.


[00:15:37] Kerri Doucette: Is there a PLA process in place if the blood glucose has been, has not been taken? So if the dietary. Staff goes to the patient's room, do they know whether that blood glucose has been taken or not? And one suggestion might be to use a whiteboard where you put the breakfast, lunch and dinner, blood glucoses on the board.


[00:15:58] Kerri Doucette: And if that blood glucose isn't there for say, lunch, the um, dietary tech knows not to leave the tray there and they leave it with the unit secretary who can then notify the nurse. It's also helpful to educate the patient on why they're on insulin and that why it's important to get their blood sugar checked before they start eating so that if that tray happens to get delivered to them and they haven't had their blood glucose checked yet, they can reach out, um, to the nurse to get their blood glucose checked before they start their meal.


[00:16:32] Kerri Doucette: The next area is that point of care blood glucose check. Having a standard process for checking those blood glucoses and having a communication plan in place, um, is also important to have a policy on rechecking those blood glucoses if they're greater than 30 minutes old. Some sites do carb counting for insulin management for the prandial insulin dosing.


[00:16:58] Kerri Doucette: So if your site does that, it's helpful to have those grams of carbohydrates on the meal tray ticket and to provide carbohydrate counting education and having a process for documenting the grams of carbs consumed in the EMR. Also, consider supplements, because sometimes they are not on the meal tray ticket, and so those carbs from the supplements may need to be added to the total amount of carbohydrates consumed on the tray.


[00:17:28] Kerri Doucette: Also consider the insulin type, um, which analog is being used when you're considering the timing of your insulin? Is your timing gonna be at the start of the meal versus 30 minutes, within 30 minutes after the meal? And we'll talk a little bit more about that in just a minute. And it's also beneficial if you can combine the correction and the meal bolus together.


[00:17:52] Kerri Doucette: Do you have a process for meal tray pickup? Is there a process to ensure that the carbohydrates consumed have been documented before the tray is picked up? And an example of this might be that once the nurse has counted the carbohydrates that they've administered the insulin, they put a check mark on the meal tray ticket.


[00:18:13] Kerri Doucette: And that might be a indicator to the dietary staff that the tray is ready to be picked up. Leaders within healthcare organizations are called to be change agents in an ever changing environment, and must recognize processes that need to change to improve care and outcomes, as well as factors that impede change.


[00:18:33] Kerri Doucette: Lack of knowledge among the healthcare team in limited protocols for managing insulin in the hospital, perpetuate poor care. Various approaches have been taken to address the challenges related to the meal triad. Best practice. At the University of Pittsburgh Medical Center, a diabetes nurse specialist and a clinical pharmacy specialist spent three months evaluating causes and trends of hypoglycemia.


[00:18:59] Kerri Doucette: They discovered that patients with diabetes were receiving and consuming their bedtime snacks early, causing elevated postprandial blood glucoses at bedtime. Nurses were treating the elevated blood glucoses with correction insulin and the patients were experiencing hypoglycemia as a result of treating the postprandial blood glucose.


[00:19:21] Kerri Doucette: The team took action by completing a manual audit on 12 inpatient nursing units. Over 10 days, reported the findings to numerous committees and established a hypoglycemia reduction goal, Educated the nurses and performed a re-audit. They were successful in changing the meal triad workflow and demonstrated a 20% reduction in severe hypoglycemia.


[00:19:47] Kerri Doucette: The timeline for this quality improvement project took around three years. In recent years, the healthcare industry has adopted the business industry's approach to failing fast by designing small scale change models that allow for gaps to be identified quickly, rapid, iterative, improve. To changes based on lessons learned and applying principles of efficiency to reach goals faster by taking the fail fast approach.


[00:20:18] Kerri Doucette: The Meal Triad Quality Initiative can be completed much faster. By gathering feedback quickly, the project can be modified for effectiveness. The timeline may need to be adjusted based on staffing demands, competing priorities, and unpredictable findings that impact the project timeline. Here's an example of an audit tool to evaluate the timing of the meal triad on a med surge unit.


[00:20:44] Kerri Doucette: In this example, the data was collected over a two week period by a diabetes educator. The point of care, blood glucose and insulin administration times were obtained from the electronic health record. While the meal time was determined by the time the tray was delivered to the patient, the dietary staff were trained to write the time of the tray delivery on the meal tray ticket.


[00:21:06] Kerri Doucette: And to leave the ticket on the patient's door to be collected by the diabetes educator. The data entry was manual, but the Excel spreadsheet calculated the timing. At Glytec, we are exploring the possibility of making a tool like this available. If you would be interested in having something like this available or have suggestions for the audit tool design, please reach out to me. I would love to get your input, especially from those with quality improvement


[00:21:30] Kerri Doucette:. So several opportunities were discovered by performing this audit. The evidence based goal for point of care blood glucose to correction insulin administration is 30 minutes, and this hospital goal was 45 minutes. The results show that at breakfast, the timing of blood glucose checks to insulin administration ranged from 18 minutes to 2 hours and 43 minutes with the average duration of 1 hour and 14 minutes.


[00:22:02] Kerri Doucette: Evaluating the workflow, the staff discovered that patient care technicians were checking the blood glucoses at 7:30, and the nurses were administering the correction and prandial insulin together after the patient ate breakfast, often around 8:30 or 9:00. The hospital planned to develop a policy that blood glucoses greater than 30 minutes old had to be rechecked prior to giving correction insulin and modified the workflow so that patient care technician would check the blood glucoses when the trays were on their way to the units.


[00:22:31] Kerri Doucette: Nurses were alerted and could plan their time accordingly to be able to administer the insulin within 30 minutes. This change in workflow reduced the lag time on point of care blood glucose to insulin administration to 30 to 40 minutes.


[00:22:50] Kerri Doucette: It's not shown on this slide, but they also found that the duration of point of care blood glucoses to the time dinner was delivered ranged from 10 minutes to an hour and 24 minutes, with most around 55 minutes. By performing this audit, they saw that the blood glucose checks were scheduled at 4:00 PM but meal trays weren't scheduled to be delivered until 5:00.


[00:23:15] Kerri Doucette: This simple discovery allowed them to change the time that the blood glucose was gonna be scheduled, 5:00 PM and they developed a process for notifying the nursing staff when the trays were on their way, um, and this reduced the timing of their meal triad. This is an example of a simple process map.


[00:23:36] Kerri Doucette: Mapping the process can help identify process metrics to measure, particularly where the steps in the process are broken and need optimization. In this example, the outcome metric is hypoglycemia rates and the process impacting hypoglycemia rates is the meal triad.


[00:23:59] Kerri Doucette: When to administer mealtime with correction? Insulin may vary based on the patient's status. In the hospital, many wanna wait to give the mealtime insulin until they see how many carbs the patient has consumed. Patients who meet certain criteria may be appropriate for dosing the prandial dose at the start of the meal based on the anticipated amount of carbohydrates consumed.


[00:24:21] Kerri Doucette: These patients should be alert and oriented, have be able to verbalize what they plan to consume and have consistent PO intake and be able to feed themselves. However, special consideration should be consi, um, consider for renal patients and those who had a recent hypoglycemic event. However, patients with an altered mental status or a history of poor PO or nausea, vomiting, unable to feed self, those patients, um, should really be dosed after the start of the meal to determine how much they actually consumed.


[00:24:59] Kerri Doucette: So we've covered a lot of information today and I just wanna highlight four key takeaway. A safe and effective meal triad process includes communicating tray delivery, blood glucose checks and carb amounts consumed. Checking a patient's blood glucose immediately before the meal and no more than 30 minutes prior to insulin administration. Administering mealtime correction insulin with the meal or no later than 30 minutes after the first bite of food. And count carbohydrates accurately and include those supplements.


[00:25:31] Kerri Doucette: Thank you so much for your time today. If you have any questions, please reach out and I'll be sure to follow up with you. Have a great day.


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