Insulin and Diabetes Education: An Intervention to Decrease Medication Errors

Nursing professional development practitioners (NPDPs) at an academic hospital brought attention to insulin administration errors on the intensive care units, women's specialty units, and acute care floors. This project aims to decrease insulin administration errors at this academic hospital. The objectives include 1) identifying knowledge gaps and other barriers to safe insulin administration and 2) intervening based on identified gaps and barriers. Nursing leadership teams will help facilitate process changes and education as necessary. Over the following year, insulin administration errors will continue to be tracked. A comparison of frequency and type of errors will then be performed to evaluate the success of interventions.

INSULIN AND DIABETES EDUCATION INTERVENTION Insulin and Diabetes Education: An Intervention to Decrease Medication Errors Jordan Hill, BSN, RN University of Utah April 22, 2022 In partial fulfillment of a Master of Science degree College of Nursing Major: Nursing Specialty: Education 1 INSULIN AND DIABETES EDUCATION INTERVENTION 2 Introduction Insulin administration is a daily task for most registered nurses working in critical and acute care settings. While its use is routine in these settings, insulin is a high-risk medication frequently associated with medication errors (Cartwright, 2020; Harada et al., 2017; Hill, 2018; Iflaifel et al., 2019). Incorrect dosing, omitted doses, and inappropriate timing of administration are some of the most cited errors (Harada et al., 2017; Hill, 2018; Lim et al., 2020). The adverse sequelae of these errors range from transient hypoglycemia or hyperglycemia to seizures, diabetic ketoacidosis (DKA), and death (Harada et al., 2017; Iflaifel et al., 2019). The reasons for insulin administration errors are complex and multifaceted, and multiple different approaches have sought to decrease the incidence of errors. Harada et al. (2017) conducted a study to evaluate the effectiveness of a standardized order sheet in reducing insulin errors. More than 35 different order sheets for sliding scale insulin (SSI) existed before standardization. After standardization to one order sheet, there was a significant decrease in SSI administration errors. Another study looked at reducing rates of hyperglycemia during hospitalization (Watts et al., 2021). A nursing education competency was employed. One aspect of this competency addressed a knowledge gap related to the omission of basal insulin doses in patients with NPO orders. The hospital where this study took place had previously attempted to decrease the omission of basal insulin doses by requiring nurses to notify the provider if they held basal insulin for any reason; however, this intervention was not effective. For the nursing education competency, diabetes educators and a clinical nurse specialist created an educational poster and a pre and post-test to be completed in conjunction with a review of the poster. The poster outlined the hospital policy: nurses should give half of a patient's basal insulin when the patient is NPO INSULIN AND DIABETES EDUCATION INTERVENTION 3 prior to a procedure. Only 50% of nurses correctly answered the pre-test question asking what dose of basal insulin to give when a patient is NPO for a procedure. That number increased to 91.5% on the post-test, indicating that the competency poster effectively addressed this knowledge gap. An integrative literature review conducted by Alqahtani (2022) identified additional interventions proven effective for reducing insulin errors. The first effective intervention identified was a significant reduction of insulin errors with the implementation of electronic health records (EHRs). Next, the review looked at the effectiveness of educational interventions. Online learning modules for nurses proved valuable. In one of the reviewed studies, insulin errors decreased from 14.8% to 1.7% over six months following the introduction of an online educational module. The literature did not include extensive details about the content of various educational interventions but did show that they can be an effective means for decreasing errors. Lastly, the literature review showed that requiring double checks of insulin doses prior to insulin administration can reduce errors. The author pointed out that double-checking medications increases the workload for nurses, but it is a safer practice for insulin administration. Nursing professional development practitioners (NPDPs) at an academic hospital brought attention to insulin administration errors on the intensive care units, women’s specialty units, and acute care floors. This project aims to decrease insulin administration errors at this academic hospital. The objectives include 1) identifying knowledge gaps and other barriers to safe insulin administration and 2) intervening based on identified gaps and barriers. Nursing leadership teams will help facilitate process changes and education as necessary. Over the following year, insulin administration errors will continue to be tracked. A comparison of frequency and type of errors will then be performed to evaluate the success of interventions. INSULIN AND DIABETES EDUCATION INTERVENTION 4 Methods This project followed a continuous quality improvement (CQI) process utilizing the PlanDo-Study-Act model. During the planning phase, a gap analysis was performed by reviewing reported errors and results of a survey sent to acute care, women’s and children’s, and critical care registered nurses (RNs). Reported errors were compiled from this academic hospital's Report and Learn (RL) system. The RN survey consisted of 15 questions, three of which included demographic variables – level of experience as an RN and work setting (see Appendix). The other 12 questions assessed knowledge regarding insulin administration and current practices related to blood glucose monitoring and insulin administration. The gap analysis revealed multiple needed interventions. An education kit was created and included an online learning module for RNs and an educational flyer. Educational materials reflected knowledge and practice gaps identified during the needs assessment. Additionally, the gap analysis identified systems issues such as equipment malfunction, challenging staffing ratios, and high patient acuity. Specific data on insulin errors and hospital-wide trends was presented to management teams. They were invited to assign the online learning module to all nurses on their units and to post the educational flyer. They were also asked to further assess and address identified systems issues on their units. One year after implementing interventions, RL data will be analyzed, and a follow-up survey will be sent to RNs to evaluate whether or not there was a decrease in insulin administration errors. No IRB approval was required for this project. Results Reported Errors Analysis The analysis of reported errors in the RL system over the past two years revealed patterns INSULIN AND DIABETES EDUCATION INTERVENTION and themes (see Figure 1). Incorrect doses, missed doses, and incorrect or unclear orders from providers were the most commonly reported errors. Other categories of reported errors included pharmacy dispense issues, storage and disposal issues, administration of incorrect insulin type, errors in implementing the DKA protocol, and insufficient blood glucose monitoring. In some cases of wrong dose administered and wrong insulin type administered, it was clear that the mistake could have been avoided by properly using the bedside scanning process prior to administration. In several instances of administration of the wrong dose, the nurse accidentally treated the wrong blood glucose level. Contributing factors included: miscommunication between the nurse aide who had obtained the blood glucose reading and the nurse administering the medication, and the nurse treating a blood glucose reading in the patient's chart that was not the most recent result. A survey was created to assess knowledge and practice gaps among nursing staff based on this data. 5 INSULIN AND DIABETES EDUCATION INTERVENTION 6 Figure 1 Insulin RL Data 2020 &2021 30% 25% 20% 15% 10% 5% 8% 2% 17% Related to treating wrong BG 18% 12% 0% 10% 9% 4% 2% 5% 3% 2% 7% Related to improper bedside scanning Contributing factors unclear Survey Respondents Ninety-one nurses from the critical care, acute care and rehabilitation, and women’s and children’s service lines responded to the survey. The majority of respondents had greater than five years of nursing experience and worked on acute care and rehab units. INSULIN AND DIABETES EDUCATION INTERVENTION Figure 2 Survey Respondent Demographics RN Level of Experience 13% <1 year 41% 19% 1-2 years 3-5 years >5 years 27% RN Service Line 18% Acute Care and Rehab 51% 30% Critical Care Women's and Children's 7 INSULIN AND DIABETES EDUCATION INTERVENTION 8 Survey Results Survey results exposed knowledge barriers and practice gaps (see Table 1 & 2). When asked about five unsafe practices identified in the reported errors, 40% to 66% of nurses reported that no barriers to safe practice exist for four of the five practices. This seeming lack of awareness indicates that attention needs to be drawn to the identified unsafe practices. A few survey questions elicited significant barriers to safe practice. When asked what barriers prevent them from scanning insulin prior to administration, most nurses cited malfunctioning bedside scanners. In their commentary, nurses indicated that they often do not have time to troubleshoot broken scanners, so they skip the scanning process if they encounter equipment problems. When asked what prevents nurses from waiting for the most recent blood glucose result to appear in the charting system before insulin administration, most reported that the glucometer does not get docked promptly enough. When asked what other barriers inhibit safe insulin administration, nurses reported that nurse-to-patient ratios, patient acuity, and unclear orders are barriers. Knowledge questions indicated that most nurses who took the survey understand insulin dosing and administration, except for basal insulin administration when a patient is NPO (see Table 3). INSULIN AND DIABETES EDUCATION INTERVENTION 9 Table 1 RN Survey Results Survey Question No Distractions Lack of EHR "What barriers prevent Barriers Time Issues you and your peers from…." Q1 typing the correct 60 24 12 9 insulin dose into the MAR prior to administration…? Q3 scanning insulin 36 8 13 16 prior to administration? Q5 checking the 51 19 11 3 computer screen for scanning errors prior to administration of insulin? Q7 reading back blood 39 20 11 glucose results when they are reported by the HCA? Q9 ensuring that the 10 16 most recent blood glucose result has populated in Epic prior to administration of insulin? Note. Respondents could select more than one response per question. Equipment Issues Other 6 46 6 16 10 36 80 17 INSULIN AND DIABETES EDUCATION INTERVENTION 10 Table 2 RN Survey Themes Overarching Themes Specific Barriers Illustrative Quotes Equipment Issues Broken bedside scanners “Busy time of day, scanners often don’t work properly. Which takes time we feel we sometimes don’t have to fix the scanner.” “Scanners are often broken… sometimes I can use my phone… it’s just a pain to use since it takes more time to log in.” “scanner not reading the insulin label." “They don’t dock right away.” “This would be the only reason I’d give insulin without result population into EPIC… 90% of the time if I’m in the room with HCA, I’ll glance at the result on the glucometer and type it into the comments.” “The HCA who does the glucose check is sometimes late with getting the blood sugar and/or not docking the glucometer quickly enough.” “Talking to patient while giving meds.” “Sometimes you get talking to your patient and scan the medication and don’t recognize that it didn’t go through properly or that it was the wrong med.” “We may be distracted by patient demands.” Glucometer not docked in a timely fashion Distractions Interaction with patients INSULIN AND DIABETES EDUCATION INTERVENTION 11 Overarching Themes Specific Barriers Illustrative Quotes Lack of Time Busy/challenging staffing ratios “…mealtimes are the busiest time of day on the floor.” “…the main problem is just getting the HCA to do the glucose in a timely fashion so I know how much insulin to dose.” “I may not always have the ability to write down the blood sugar at the time it’s reported and the HCA.” “If you’re busy doing other things and didn’t hear your aide.” “Busy doing other patient care.” “On the acute care floors, HCAs and RNs have multiple pts at once who have insulin orders. This leads to incorrect reporting (wrong pt or glucose) or incorrect administration of insulin (misremembering which glucose for which pt). High pt:RN/HCA ratios and pt acuities leave little time to collect glucose and administer everyone’s insulin on time since they’re usually due at the same time.” “I have multiple patients and I don’t always have time to make sure the HCA has docked the glucometer in a timely manner.” INSULIN AND DIABETES EDUCATION INTERVENTION 12 Overarching Themes Specific Barriers Illustrative Quotes Inconsistent medication preparation process Lack of standardized doublecheck process/med prepared outside of the room Provider Ordering Issue Incorrect/confusing orders “I was taught to always have another nurse check my dose, so I pull up dose before going into pts room.” “Forgetting to bring bottle into room.” “…checking dose outside room of pt with another nurse.” “Need of a double check to not only just hear you read the order but double check via the patients EMAR." “Epic should require DUAL SIGN OFF of insulin." “…orders are wrong…pt has been doing this carb counting and insulin administration for a long time.” “Doctors put in standard orders which can differ from the patients home regimen. They don’t take time to personalize the order to the patient.” “Rarely orders are confusing or duplicate orders that conflict with each other such as, carb count and sliding scale.” INSULIN AND DIABETES EDUCATION INTERVENTION 13 Table 3 RN Survey Knowledge Questions Survey Question You are caring for a diabetic patient with the following order set… What dose of insulin would you administer? (Order set, carb count on meal ticket, and most recent blood sugar provided.) RN Response (n=91) Selected correct dose: 82% Selected supplemental dose only: 9% Selected prandial dose only: 8% Selected no insulin to be administered: 1% Which of the following syringes are appropriate for insulin administration? (*More than one response allowed.) 1 mL TB syringe: 9 (10%) Insulin syringe: 91 (100%) 1 mL syringe: 3 (3%) 10 mL syringe: 0 (0%) 3 mL syringe: 0 (0%) What unit of measurement is used for insulin administration? units: 100% mL: 0% mg: 0% mcg: 0% You are caring for a diabetic patient receiving continuous tube feeds. The patient will be NPO at midnight, and tube feeds will be held at that time for a procedure. They have an order for their home dose of Lantus, 10 units, at 2100. What course of action would you take? Hold the dose of Lantus and notify provider: 41% Recommend dose reduction to provider prior to administration: 25% Give the full dose of Lantus: 20% Other: 10% Give 50% of the dose of Lantus: 2% Give 70% of the dose of Lantus: 2% Evaluation of Interventions The above-identified interventions – education and addressing systems issues through nursing leadership teams – have not yet been implemented, so the evaluation results will be compiled and analyzed within a year after implementation. Discussion Key Findings This quality improvement project found that insulin administration errors continue to be a common occurrence, and multiple factors contribute to these errors. Analysis of self-reported INSULIN AND DIABETES EDUCATION INTERVENTION 14 insulin errors, followed by a survey of registered nurses on various inpatient units, exposed frequent unsafe practices, knowledge gaps, and resultant mistakes. A lack of knowledge surrounding the function of basal insulin was one significant finding. This was consistent with the literature that looked at the need for an educational intervention to address this aspect of hyperglycemia in the hospital setting (Watts et al., 2021). Another major finding was that nurses overwhelmingly fail to identify specific barriers to safe practice even though unsafe practices occur. Educational interventions coupled with other systems-level interventions have the potential to reduce insulin errors at this academic hospital successfully. Strengths and Limitations This project had multiple strengths. Many reports over two years were extracted from the RL system. These provided sufficient data to identify themes in both types of errors and potential causes for errors. The RN survey was created based on this data so that the reasons for unsafe practices could be better understood. Ninety-one nurses from acute care, critical care, and women's and children's units responded. A wide variety of information and perspectives were gleaned from the responses. Limitations were also evident. The RL system is a self-report system, so it can be assumed that many errors were not captured for analysis through this data. The RN survey was also voluntary and was not sent to all units throughout the hospital. This means that there was some voluntary response bias, and the perspective of some specialties was not represented. Lessons Learned & Recommended Next Steps Multiple issues need to be addressed to decrease insulin errors and promote patient safety. The next step is completion of education by nurses. This education will reinforce the INSULIN AND DIABETES EDUCATION INTERVENTION 15 appropriate bedside medication scanning process, the correct syringes for insulin administration, and the function of basal insulin. Extensive education is needed to correct basal insulin practices in NPO patients and encourage discussions about dose reduction between nurses and providers. Many systems issues were identified as contributing to unsafe insulin administration. Leadership teams need to look at these problems and work with teams throughout the hospital to promote safe insulin administration. The number of reported errors related to provider orders indicates a need for provider education. Pharmacy dispense issues were also cited in multiple instances, so collaboration with pharmacists is needed. Informaticists may be able to modify the EHR so that the blood glucose reading that should be treated at a given time is more evident. Nursing leadership may also want to assess the benefits of instituting a dual sign-off process for insulin administration. Conclusion The findings of this project reinforce the need for both educational and systems-level interventions to increase insulin safety. Insulin is a high-risk medication and should be treated as such. In this hospital and many others in the literature, incorrect dosing of insulin and omitted insulin doses are frequent. The consequences of these errors can be grave and may even result in death. The implemented educational intervention, and future systems-level interventions, have the potential to empower nurses to provide safe care and prevent harm to patients. INSULIN AND DIABETES EDUCATION INTERVENTION 16 References Alqahtani. (2022). Reducing potential errors associated with insulin administration: An integrative review. Journal of Evaluation in Clinical Practice. https://doi.org/10.1111/jep.13668 Cartwright, A. (2020). Insulin safety: What is all the fuss about? Practice Nursing, 31(11), 467– 471. https://doi.org/10.12968/pnur.2020.31.11.467 Harada, Suzuki, A., Nishida, S., Kobayashi, R., Tamai, S., Kumada, K., Murakami, N., & Itoh, Y. (2017). Reduction of medication errors related to sliding scale insulin by the introduction of a standardized order sheet. Journal of Evaluation in Clinical Practice, 23(3), 582–585. https://doi.org/10.1111/jep.12674 Hill. (2018). Insulin safety: avoiding mistakes and reducing risk. Primary Health Care, 28(1), 37–41. https://doi.org/10.7748/phc.2018.e1337 Iflaifel, M., Ryan, K., Crowley, C., & Iedema, R. (2019). Understanding safety differently: Developing a model of resilience in the use of intravenous insulin infusions in hospital inpatients—a feasibility study protocol. BMJ Open, 9(7), e029997–e029997. https://doi.org/10.1136/bmjopen-2019-029997 Lim, Jong, M., Chew, D. E. K., & Lee, J. Y.-C. (2020). Impact of timing between insulin administration and meal consumption on glycemic fluctuation and outcomes in hospitalized patients with type 2 diabetes. Journal of Pharmacy Practice, 33(4), 449– 456. https://doi.org/10.1177/0897190018818908 Petite, S. E., Huenecke, J., & Tuttle, N. (2020). Evaluation of Basal Insulin Dose Reductions in Hospitalized Patients With Diabetes While Unable to Eat. Hospital Pharmacy, 55(4), 246–252. https://doi.org/10.1177/0018578719841029 INSULIN AND DIABETES EDUCATION INTERVENTION 17 Watts, S. A., Nemes, D. R., & Davian, T., Jr. (2021). Inpatient hyperglycemia nursing education competency. MedSurg Nursing, 30(4), 257+. https://link.gale.com/apps/doc/A672450807/AONE?u=marriottlibrary&sid=bookmarkAONE&xid=aab8572c INSULIN AND DIABETES EDUCATION INTERVENTION 18 Appendix Insulin Survey This anonymous survey will be used for quality improvement purposes to decrease medication errors related to insulin administration. * Required Incorrect Insulin Doses Over the past two years, 31% of inpatient insulin RLs involved administration of incorrect insulin doses. 1 What barriers prevent you and your peers from typing the correct insulin dose into the MAR prior to administration of sliding scale and/or mealtime (carb count) insulin? * Lack of time Not part of my workflow issues Distra ctions Other Epic INSULIN AND DIABETES EDUCATION INTERVENTION No barriers exist 2 Please elaborate on the barriers you selected above. * 19 INSULIN AND DIABETES EDUCATION INTERVENTION 20 BCMA Scanning Over the past two years, 13% of RLs involving incorrect insulin doses, incorrect type of insulin given, and incorrect timing of insulin could have been avoided if BCMA scanning had been used appropriately. 3 What barriers prevent you and your peers from scanning insulin prior to administration * Malfunctioning Bedside Scanners Lack of time Not part of my workflow Distractions Issues with Epic Other No barriers exist 4 Please elaborate on the barriers you selected above. * INSULIN AND DIABETES EDUCATION INTERVENTION 21 Scanning Errors Over the past two years, 15% of RLs involving wrong insulin doses and 60% of RLs involving administration of incorrect insulin type were related to not scanning the medication, or scanning the medication away from the computer and administering it before checking the screen. 5 What barriers prevent you and your peers from checking the computer screen for scanning errors prior to administration of insulin? * Lack of time Distractions Epic issues Bedside scanner malfunctioning Not part of my workflow Other No barriers exist 6 Please elaborate on the barriers you selected above. * INSULIN AND DIABETES EDUCATION INTERVENTION 22 Treating the wrong blood glucose reading Over the past two years, 41% of RLs involving administration of incorrect insulin doses were related to communication breakdown between RNs and HCAs, and/or not waiting for blood glucose results to load into Epic. 7 What barriers prevent you and your peers from reading back blood glucose results when they are reported by the HCA? * It doesn't seem necessary Lack of time Distractions Not part of my workflow Other No barriers exist 8 Please elaborate on the barriers you selected above. * INSULIN AND DIABETES EDUCATION INTERVENTION 23 9 What barriers prevent you and your peers from ensuring that the most recent blood glucose result has populated in Epic prior to administration of insulin? * Lack of time Equipment malfunctioning Glucometer does not get docked in a timely manner Not part of my workflow Other No barriers exist 10 Please elaborate on the barriers you selected above. * INSULIN AND DIABETES EDUCATION INTERVENTION 24 Other Barriers 11 Which of the following are additional barriers to safe insulin administration for you and your peers? * Unclear orders Pharmacy medication dispense issues Patient acuity Nurse to patient ratios Lack of understanding how insulin works Other No barriers exist on my unit 12 Please elaborate on the barriers you selected above. * INSULIN AND DIABETES EDUCATION INTERVENTION 25 Please answer the following questions to the best of your ability. 13 You are caring for a diabetic patient receiving continuous tube feeds. The patient will be NPO at midnight and tube feeds will be held at that time for a procedure. They have an order for their home dose of Lantus, 10 units, at 2100. What course of action would you take? * Hold the dose of Lantus and notify provider Give 50% of the dose of Lantus and notify provider Give 70% of the dose of Lantus and notify provider Recommend dose reduction to provider prior to administration. Give the full dose of Lantus Other: 14 If you selected "other", please explain. INSULIN AND DIABETES EDUCATION INTERVENTION 26 15 You are caring for a diabetic patient with the following order set: Insulin lispro 1:5 Carb Ratio 0-30 Units. Admin Instructions: Give with meals unless specified otherwise. RN to verify meal info from a meal ticket. Patient to call RN for insulin when meal delivered, when possible. Give 1 unit of insulin for every 5 grams of carbohydrates to be consumed. 1 units insulin : 5 grams carbohydrates 2 units insulin : 10 grams carbohydrates 3 units insulin : 15 grams carbohydrates 4 units insulin : 20 grams carbohydrates 5 units insulin : 25 grams carbohydrates 6 units insulin : 30 grams carbohydrates 7 units insulin : 35 grams carbohydrates 8 units insulin : 40 grams carbohydrates 9 units insulin : 45 grams carbohydrates 10 units insulin : 50 grams carbohydrates 11 units insulin : 55 grams carbohydrates 12 units insulin : 60 grams carbohydrates 13 units insulin : 65 grams carbohydrates 14 units insulin : 70 grams carbohydrates 15 units insulin : 75 grams carbohydrates 16 units insulin : 80 grams carbohydrates 17 units insulin : 85 grams carbohydrates 18 units insulin : 90 grams carbohydrates 19 units insulin : 95 grams carbohydrates 20 units insulin : 100 grams carbohydrates 21 units insulin : 105 grams carbohydrates 22 units insulin : 110 grams carbohydrates 23 units insulin : 115 grams carbohydrates 24 units insulin : 120 grams carbohydrates 25 units insulin : 125 grams carbohydrates 26 units insulin : 130 grams carbohydrates 27 units insulin : 135 grams carbohydrates 28 units insulin : 140 grams carbohydrates 29 units insulin : 145 grams carbohydrates 30 units insulin : 150 grams carbohydrates INSULIN AND DIABETES EDUCATION INTERVENTION 27 If patient exceeds max amount allowed, notify the provider on call for additional orders. AND Insulin lispro AC & HS 0-10 Units. Admin Instructions: SUPPLEMENTAL insulin is to be given in addition to scheduled meal/tube feeding/TPN insulin regardless of patient's oral status unless instructed otherwise by provider. Blood Glucose: < 70 mg/dl give orange juice or ½ amp D50 IV if NPO or not eating. Recheck blood glucose in 15 minutes and repeat above steps till blood glucose is above 100 mg/dL < 80 mg/dl Hold scheduled insulin 80-180 mg/dl no supplemental insulin, continue scheduled insulin if any ordered 181-205 mg/dl = 2 units 206-230 mg/dl = 3 units 231-255 mg/dl = 4 units 256-280 mg/dl = 5 units 281-305 mg/dl = 6 units 306-330 mg/dl = 7 units 331-355 mg/dl = 8 units 356-380 mg/dl = 9 units >380 mg/dl = 10 units You are preparing to administer their 1200 insulin. At 1130 the patient's blood sugar was 209. They plan to eat their entire meal and their meal ticket is as follows: 1 sandwich Cheeseburger (KCAL 660, CHO 38g) 2 pc Ketchup Packet (KCAL 20, CHO 6g) 1 4 slices Pickle Plate (KCAL 23, CHO 5.47g) 1 4 oz cup Chocolate Ice Cream (KCAL 130, CHO 17g, FLD 118mL) What dose of insulin would you administer? * 3 units 13 units 16 units 0 units INSULIN AND DIABETES EDUCATION INTERVENTION 16 Which of the following syringes are appropriate for insulin administration? * A B C D E F 28 INSULIN AND DIABETES EDUCATION INTERVENTION 17 What unit of measurement is used for insulin administration? * mL units mg mcg 18 What is your level of nursing experience? * <1 year 1-2 years 3-5 years >5 years 19 What service line do you work for? * Critical Care Acute Care and Rehab Women's and Children's 20 What specific unit do you work on? * 29