I'm hoping to find out what other tertiary care hospitals do for their sliding scale insulin. I've worked at the same hospital since becoming a nurse, so I want to see what other hospitals around the country do.
At my hospital, if a pt is on QID sliding scale insulin, it's timed for 0730, 1130, 1630, 2230. It's up to the MD to decide what the coverage will be i.e. humalog vs humulin. My hang up with it is it seems like we don't really do it at meal times. For example, I was taught that we do finger sticks in the AM on night shift (so usually around 0500 or 0600) and provide insulin coverage if needed. This is regardless of if the pt is eating breakfast soon or not. However, this doesn't make sense to me, especially when giving humalog.
If anyone could share their experience, I'd really appreciate it. Also, if anyone knows of any evidence based publications on the topic, I'd appreciate that as well.
Aug 16, '17
Because meals are delivered at varying times throughout the hospital our computer system just puts times such as 7a, 12n, 5p, and 9p for all before meal blood sugar checks and sliding scale orders. . The order does have a clarification with it that says "before meals". So on one unit breakfast may come at 7a but on an upper floor it might come until 8a. So the blood sugar might be done at 6:40a with sliding scale at 6:55a on a 7a breakfast floor but not until 7:40a and 7:55a on the floor that gets breakfast at 8a. Also if a patient wants to wait and eat lunch an hour later, until their spouse arrives we would not give their insulin until we knew they were going to be eating.
I agree if people on your unit are just doing blood sugar checks and sliding scale with no regard to meals that is strange.
Last edit by RNKPCE on Aug 16, '17
: Reason: cla
Aug 16, '17
A true correctional sliding scale isn't based on when or how much they are eating or if they are eating at all. A common practice in hospitals however is to combine the correctional and nutritional doses, often including different doses for HS or if they are NPO. A sliding scale might say to give 6 units for a BG of 270 before meals, but only 2 units if it's HS, this is because 4 units of the sliding scale are for nutritional coverage.
If the purpose of sliding scale is to cover both correctional and nutritional needs, then you're correct, they should be given closer to meal times. If it's just correctional, then 0500 is fine. As the PP pointed out, the times in the computer are not necessarily the time they should be given, they are sometimes just placeholders, with "AC" being the actual ordered time.
As to why you were taught to provide breakfast AC coverage at 0500 or 0600, it's not unheard of for the day shift nurses to tell the night shift nurses they should be giving the breakfast AC dose, which is not good practice since this means giving the dose often hours before the patient eats. If the coverage includes nutritional coverage, then they day nurses should be giving it.
Aug 17, '17
Thank you both! Some patients are given a separate bolus insulin with meals. The sliding scale usually just says "to be given with bolus insulin at meals" but not everyone has bolus insulin. Is it common to use humalog as a correction insulin without meals? I was always taught humalog is given when a tray is in front of the patient.
edit for spelling
Aug 25, '17
My hospital says that the fingerstick must be done before the patient begins eating and the insulin must be given no later than 60 minutes after the fingerstick. Meal-based sliding scale coverage (Humalog) is calculated on whether the pt ate > or < than 45g carbs. If the pt is a slow eater and hasn't finished their tray by 60 minutes, I guess you cover them for what they've eaten so far... (I work nights, so I don't have to troubleshoot this!)
Because of this tight administration window, night shift doesn't do the AM AC fingerstick anymore.
We're also not supposed to give 2 doses of insulin less than 3 hours apart (so if the patient gets their breakfast late and then lunch comes 2 hours later, we're supposed to hold their tray for an hour so that we can give the lunchtime insulin correctly). This is to prevent dose-stacking and hypoglycemia; I assume it doesn't improve patient satisfaction at all!
Aug 28, '17
SSI is its own order set. Low, medium and high. (For example, the low SSI would be 1 unit novolog for a blood glucose of 150-200, 2 units for 201-250, etc. With blood glucose of 351 or higher, give 5 units and notify provider.) The order set includes two PRN orders for novolog (one specifies AC/HS, another specifies q6h if pt is NPO) and a whole host of hypoglycemia protocols. We check sugars at 0500, 1100, 1600 and 2100 to correspond with meal times of 0600, 1200, 1700 and night tour's med pass at 2200. Some patients will have scheduled novolog with meals, and some will have both scheduled and sliding scale.
It is not perfect...
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