For more than 20 years, I have had the pleasure of leading inpatient and ambulatory diabetes programs focusing on strategic and innovative redesign initiatives that improve patient outcomes. During this time, I became keenly interested in the meal triad process. In a perfect world, the meal triad revolves around the seamless coordination of obtaining a blood glucose reading, delivering a tray of food to the patient, assessing the amount of carbohydrates consumed, and administering rapid-acting insulin – all within 30 to 45 minutes.
The unfortunate truth, however, is that many health systems are not aware of the risks associated with this mistimed workflow, how it causes insulin administration errors and can potentially harm patients. This is further compounded with ongoing health system challenges, like limited standardization, poor communication, staffing shortages, conflicting priorities and countless other barriers that result in unsafe insulin timing. Together, these factors may lead to hospital-acquired hypo- and hyperglycemia.
During Gytec’s annual industry event, Time to Target, I shared evidence-based practices and implementation tools to adopt a sustainable and reproducible meal triad process in the inpatient setting.
Here are five focus areas and tips to achieve meal triad best practices:
- Meal Delivery: Establishing a standard delivery procedure and notification system is essential. It may be helpful if the kitchen calls to notify the unit when food trays will be delivered. That way, the staff nurses know when to check the patient’s blood sugar. Health systems should also consider simple solutions, like whiteboards, to track blood glucose and increase communication. For instance, if readings are on the whiteboard for lunch, the dietary technician can notify the nurse the food has arrived, and a blood sugar reading is needed before the patient starts eating.
- Point of Care Blood Glucose Check: By reviewing the meal delivery tips above, it’s easy to see why health systems need a proven method for checking blood glucose levels before a meal. More importantly, each health system must have a plan and policy on rechecking blood glucose if they’re over 30-45 minutes old.
- Carb Counting: Carbohydrates (carbs) cause blood sugar to rise, so monitoring intake is vital for care. Some sites perform carb counting for insulin management for the prandial insulin dosing. For more accurate carb counting and to ease the work burden on nurses, it’s helpful to have the grams of carbohydrates on the meal tray ticket. Remember, carbs can be found in supplements, too. Sometimes these are not recorded on the meal tray ticket and must be added to the total amount of carbs consumed.
- Insulin Dosing: Providers must also consider the insulin type and its timing of action. Will insulin be administered at the beginning of the meal vs. after the patient eats? Are nurses able to return in time to administer the insulin to match the rise in blood sugar? For patient and nursing satisfaction, it’s beneficial to combine the correction and the meal bolus doses. Computer-guided insulin dosing solutions can help here.
- Meal Tray Pick-Up: The final focus area is creating a system for meal tray pick-up. This workflow should include a checklist that ensures carbs consumed by the patient have been documented before the tray is picked up. It can even be as simple as putting a checkmark on the meal tray ticket once the nurse has counted the carbs and administered the insulin. That simple mode of communication is a perfect indicator for the dietary staff that the tray is ready to be picked up.
It’s no secret inpatient hypo- and hyperglycemia contribute to longer lengths of hospital stay, increased staff workload, and higher costs. Healthcare staff are critical influencers of safe insulin administration in the hospital. Now, more than ever, providers are being called on to recognize processes that need change to improve care and outcomes. The good news is that studies demonstrate improved glycemic control can occur with better coordination of blood glucose monitoring, meal delivery and carb intake evaluation, and insulin administration.
It’s beyond time that health systems master the meal triad. Catch my Time to Target presentation for a step-by-step approach that outlines how to launch an audit, identify gaps in care, spotlight opportunities for growth and spearhead a meal triad quality improvement initiative at your health system today.
