Diabetes Question

[JenTheSchoolRN, BSN, RN]

So I've been in this school nursing game for a few years and this year I got two new students diagnosed with Type 1 Diabetes. Both diagnosed within the last year or so. One is 12, the other 13.

Both have sliding scale coverage vs carb counting; there is 0 carb counting. Neither use a pump. The pump isn't an odd one for me, but the sliding scale with no carb counting is a bit for me. Both had sugars over 350 on the first day of school as well.

I'm re-educating myself to see if I missed something in the literature recently about this; any further insight for you, my nurse's station?

(PS: Welcome back to us all, though I know several of us in the Northeast are just getting back to start this school year, which others have been at it already a couple of weeks.)

[cid1]

There should be carb coverage. Do you have orders from a doctor? Call them!!

[JenTheSchoolRN, BSN, RN]

3 minutes ago, cid1 said:

There should be carb coverage. Do you have orders from a doctor? Call them!!

Yep, I've got orders. Sliding scale for short acting insulin with Lantus coverage at night. I'm reaching out to doctor's office to confirm. One of students does have an IEP with some strong challenges, so I can see the sliding scale being more applicable in this kind of case. But the other student, I talked with previous school RN and had received and clarified same orders with no carb counting.

[ruby_jane, BSN, RN]

I have never, ever heard of not counting carbs. I mean...that's what drives the need for insulin, no?

Oy. Weird question....is this paperwork from a reputable children's hospital or a random doc? Because one year I had a high school senior who'd transitioned to an adult doc (not an endo, internal med) and I got the jankiest orders from that guy...

[Feral.Cat.Herder, RN]

It sounds to be like the doctor these children are seeing is from the old school of thought and has educated himself on updated evidence-based practice.

It's called Sliding-Scale Insulin Therapy and was used often in hospitals and long-term care facilities, it's been around 40 yrs at least. It is NOT very effective in controlling blood glucose because it doesn't take into account personal factors such as weight, insulin history and diet, all this leads to a roller coaster effect for the patient. Another "old school" insulin dosing was called basal insulin which worked by giving long-acting insulin to help keep insulin levels steady throughout the day, then adding rapid-acting mealtime insulin and correction doses to regulate blood sugar levels after meals. I've used both when I worked in outside the school system.

Carb counting was new to me when I came into the school system 5 yrs ago. I must say I do like carb counting, especially with children. It seems their diabetes is managed so much better.

[JenTheSchoolRN, BSN, RN]

44 minutes ago, ruby_jane said:

I have never, ever heard of not counting carbs. I mean...that's what drives the need for insulin, no?

Oy. Weird question....is this paperwork from a reputable children's hospital or a random doc? Because one year I had a high school senior who'd transitioned to an adult doc (not an endo, internal med) and I got the jankiest orders from that guy...

Nope, orders are from a leading children's medical institution in my area.

It just feels odd to me. I've worked with several diabetic students and collaborated with their doctors/NPs/nurses and never seen a sliding scale with no carb counting in school day to day management. I'm curious about the pattern of blood glucose long term. Orders do still have that section about CGMs (student does not have one). Parent is okay with checking with student's providers (which I can anyway to clarify orders, but nice when parent is cool with it) and I'm processing how to discuss. Likely just starting with clarification that student does not need to carb count during lunch at this time and that I'm looking ahead in the school year in case carb counting is a future goal.

Yes, sliding scale is used in hospitals but even that is changing. In my area, pump management is starting to be also continued when a patient with type 1 is admitted for an issue other than their diabetes (medical need of admission depending, of course. And the person writing the orders).

[cid1]

I had a student last year with SS for BG, but I always found the mom had that put in so there wasn't math needed for correction. So instead of doing BG-120/40, it was already figured out essentially. BUT, we still counted carbs of course. Best Practice/evidence based practice is for carb counting

[JenTheSchoolRN, BSN, RN]

4 hours ago, cid1 said:

I had a student last year with SS for BG, but I always found the mom had that put in so there wasn't math needed for correction. So instead of doing BG-120/40, it was already figured out essentially. BUT, we still counted carbs of course. Best Practice/evidence based practice is for carb counting

Did student eat a very consistent carb count each day? I'm just intrigued by this for overall tight glucose control.

[cid1]

33 minutes ago, JenTheSchoolRN said:

Did student eat a very consistent carb count each day? I'm just intrigued by this for overall tight glucose control.

No, but her ss was only used for BG. We divided carbs by 8.

[BettyGirard, BSN]

How do you do variable insulin dosages without understanding what the child is consuming? I've had diabetics at all grade levels, and while perhaps you didn't "count" carbs, you needed to track what the child was eating and counting "exchanges" was easier than just about other way.

By the time the kid hits 300+ to increase their insulin is reactionary, flirts with DKA, and in the long term going to do irreparable organ damage.

[ARN]

As a mom of a type 1 kiddo I would not be happy with this treatment plan. Surprising that this is from a childrens hospital.

Jen, how is it going with this? I am so curious!