Is This Common in LTC?

[Googlenurse, ASN, BSN, RN]

There was a nurse telling me what I am doing is all wrong, but I 100% think I am right in this situation.

Patient is a diabetic. Has a sliding scale for insulin. 

It will read:  Humalog sliding scale

BS <100 0 units

100-200 Give 4 units

200-300 Give 6 Units

300-400 Give 8 units

Over 400 Call MD

What the nurse was trying to tell me is that if the patient has a blood sugar of 401 or above, she gives 8 units, and then if it is still over 400 after she checks again, she calls the MD. I told her why not just call the first time  like the order says? She did not respond.

Am I overreacting? Is this common  to do things this way in LTC? Seems everyone is reluctant to call the MD for small stuff, which then turns into larger problems.

[JKL33]

You are right. Others do things like you coworker due to ego, insecurity or external pressure.  Nevermind all of that. Just do what it says. She has no legal standing for what she is doing.

Hopefully your patient doesn't have a glucose of exactly 200 or exactly 300 though. ?

[Hoosier_RN, MSN]

Um, what part of the order is your coworker missing? Keep doing what the order says. If the MD ever states something different, or like what the other nurse is doing, get an order to do it that way

[RNperdiem, RN]

I wonder what the relationship with the doctors is like? Are they easy to get in contact with? If the staff is reluctant to call the doctor for small stuff, there is a reason. Why?

My work is easy in that the doctors are always on the unit and taking care of small issues is easy because the docs are always available in their workroom. In other places I worked, getting a hold of the patient provider was a bigger undertaking, especially on nights. 

[Googlenurse, ASN, BSN, RN]

The place is staffed with mostly agency nurses believe it or not. The nurse I was discussing this with was agency. She has been coming to this  LTC for over two years. 

[Nurse3389]

Most sliding scale in SNF's are being d/c'd but if they are ordered it usually states "0-150 1 unit, 151-200 2 units, 201-250 3 units" for example.

[Googlenurse, ASN, BSN, RN]

6 hours ago, Nurse3389 said:

Most sliding scale in SNF's are being d/c'd but if they are ordered it usually states "0-150 1 unit, 151-200 2 units, 201-250 3 units" for example.

What are the sliding scales being replaced with?

[Hoosier_RN, MSN]

6 hours ago, Nurse3389 said:

Most sliding scale in SNF's are being d/c'd but if they are ordered it usually states "0-150 1 unit, 151-200 2 units, 201-250 3 units" for example.

Haven't heard this, nor have I seen it. I PRN at a couple locally. Sliding scale is alive and well around here

[neuron]

On 11/6/2022 at 2:51 AM, Googlenurse said:

There was a nurse telling me what I am doing is all wrong,but I 100% think I am right in this situation.

Patient is a diabetic. Has a sliding scale for insulin. 

It will read:  Humalog sliding scale

BS <100 0 units

100-200 Give 4 units

200-300 Give 6 Units

300-400 Give 8 units

Over 400 Call MD

What the nurse was trying to tell me is that if the patient has a blood sugar of 401 or above,she gives 8 units,and then if it is still over 400 after she checks again, she calls the MD. I told her why not just call the first time  like the order says? She did not respond.

Am I overreacting? Is this common  to do things this way in LTC? Seems everyone is reluctant to call the MD for small stuff,which then turns into larger problems.

A lot of the doctors in LTC probably 100+ patients and are affiliated with many different facilities. They aren't even involved with the patient and haven't seen the patient in months. 

[abbnurse]

I have seen this exact sliding scale order - if the BS was 400 or greater, I called the MD.  I did not give 8 units and then wait and call the MD.  

I am so happy to be out of LTC ! 

 

[NurseDeltaInk, RN]

11 hours ago, Nurse3389 said:

Most sliding scale in SNF's are being d/c'd but if they are ordered it usually states "0-150 1 unit, 151-200 2 units, 201-250 3 units" for example.

What this nurse is saying is the sliding scale you gave us is 100-200, 200-300. If the BG is 200, do you give the lower insulin dose or the higher dose? She is correctly saying the order MUST be clarified with the PCP to clarify the scale. It is correct and safe to, for example, read: 100-200, 201-300, 301-….

Sliding scales are, in some areas, becoming a thing of the past. They are often the source of med errors. In other areas, they are still the standard. I’ve seen both. We have newer long-acting and medium-acting insulins, administered via dial pens that are starting to replace short-acting insulins that require sliding scales. 

Hope this helps!

P.S.—for the OP—I would ALSO clarify with the PCP if the order should read: >400-call PCP OR should it read >400-give 8 units and call PCP?

[Nurse3389]

Yes, that is what I meant. Thank you for assisting with the clarification. Here in Oregon (Portland Metro) the standard is to d/c sliding scales in the SNF setting, still a standard in hosptials.