Hospital/SNF and hyperglycemia

[anticoagulationurse]

Ok, this is something I have wondered about for a loooong time. Keep in mind I DO understand that cases of illness/surgery related hyperglycemia are transiently related to the physiological stresses of said conditions. But, I suspect that some of these hyperglycemic complications are directly linked to the diabetic being served a regular diet in these facilities.

I have seen/heard so many diabetic patients complain about the carbs and HS snacks when they NEVER eat such an amount at home. Prior to admission they are possibly insulin dependent or not, but end up on sliding scale insulin while an inpatient, and then are able to go off it when they get back home. I realize the timing of such episodes are linked with admissions and henceforth illnesses/injuries which further complicates my theory. Some people are not even diabetic and suddenly they are managed with insulin during an inpatient stay. What gives?

I realize diabetic diets cost more and this is one way a facility can reduce costs, by serving cheap food and white bread and fillers. However, I wonder if the sudden "need" for sliding scale insulin may somehow affect reimbursement since it may mean a higher acuity level and more nursing needs? So it is a win win for the facility to have a patient who "requires" insulin during their stay... Just a theory, an unethical one.

Am I way off track?

[iluvivt, BSN, RN]

I am certain it is multifactorial...yes a change in the diet...an increase of stress hormones...many medications and often new ones......Dextrose in IV fluids and medications....lack of exercise...not to mention I am certain there are many "diabetics" that have never really been diagnosed adn they are not at home taking their levels as often as we do.

[HamsterRN, ADN, RN]

As you point out, high starch / simple sugar foods are cheap, but they are also what Americans like to eat. As hospitals become more consumer oriented, they seem to shift to providing the same diet that helped put their patients in the hospital to begin with, such as contracting fast food franchises in their food courts. This win-win combination of satisfying the majority of "customers" and cutting costs puts healthy eaters at a disadvantage.

An expected physiological response to illness, and some of the drugs used to treat illness, is hyperglycemia, so the hospital diet is not completely to blame, although it would be interesting to see what portion it accounts for. Mixing so many drips with D5 sure doesn't help either.

That doesn't necessarily mean they need to be on sliding scales though. Except for thoracic surgery, there is actually evidence that tight control (goal of 80-110) of critically ill patients actually increases mortality compared to a goal of

[wee_oneRN]

"Ok, this is something I have wondered about for a loooong time. Keep in mind I DO understand that cases of illness/surgery related hyperglycemia are transiently related to the physiological stresses of said conditions. But, I suspect that some of these hyperglycemic complications are directly linked to the diabetic being served a regular diet in these facilities."

Most hospitals/SNFs have different types of diets: regular/low sodium/diabetic etc.. I agree that the regular diets can have a lot of carbs and sugar.

" Some people are not even diabetic and suddenly they are managed with insulin during an inpatient stay. What gives?"

If they are not diabetic, it is not the food that causes them to need sliding scale insulin. It would take much longer (and the right predisposition) on a poor diet to cause hyperglycemia. Many of the medications can cause hyperglycemia. Specifically steriods are a huge culprit. Steroids are used to treat many, many illnesses and will instantly make your blood sugar rise.

"I realize diabetic diets cost more and this is one way a facility can reduce costs, by serving cheap food and white bread and fillers. However, I wonder if the sudden "need" for sliding scale insulin may somehow affect reimbursement since it may mean a higher acuity level and more nursing needs? So it is a win win for the facility to have a patient who "requires" insulin during their stay... Just a theory, an unethical one. "

Interesting thought. You are really thinking this through. I think you are right that cheaper foods are not really the best for health. But, I don't think that a patient on a sliding scale would really be higher acuity. Many adults and children use the sliding scale at home.

[TheCommuter, BSN, RN]

When admitting a resident to a SNF, we are expected to obtain an order for finger stcik blood sugars four times daily at AC & HS on all diabetics, even if they were only checking themselves once daily or BID at home. If the diabetic is on AC/HS finger sticks at the SNF, Medicare will completely reimburse the facility for the cost of glucometer monitoring supplies. Medicare will not reimburse quite the same with a person who receives FBSS only once or twice daily.

[nminodob]

I wouldn't blame maintenance fluids too much for elevationg a pts blood glucose. If a pt receives 100 ml/hour of maintenance fluids that contain D5 that means they are getting 5 grams of dextrose an hour - and a slice of bread is only about 15 grams. Not that much additional carbohydrate.