mismanagement of diabetes in hospital

SoldierNurse22, BSN, RN · Feb 10, 2014

As Canada's system is different from the US, I don't have a great deal of personal experience to offer in your situation.

However, it is noteworthy that when I worked inpatient, our docs would confer with the patient and pharmacy to ensure that patients with pumps or regular ol' insulin schedules would continue to get their normal doses of insulin at the regular times. This was back when I worked inpatient onc and our patients would be with us for months at a time.

However, what you need to consider is that illness and/or injury changes the metabolic needs of the body. The demand for insulin changes, and it is often very difficult to control a diabetic's blood glucose when they're inpatient, even if the proven regimen from home worked really, really well. Especially if the patient comes in sick, the staff's ability to control blood glucose is going to be marginal until there's a pattern established, which often means days of back and forth for the patient.

CDEWannaBe · Feb 10, 2014

What you observed wiley is a common occurence that threatens the health of many diabetics and even kills some while they are in the hospital.

The lack of knowledge many healthcare workers have about diabetes is shockingly inadequate, outdated, and often completely wrong. Diabetes is different than most diseases because patients dose their own medication and also learn how their blood sugar is affected by different variables, so the patients quickly becomes an expert in their own disease. Some physicians and nurses are threatened by that.

In my own experience, when I was in the hospital a few years ago to give birth (after having a healthy pregnancy and a 5.1 A1c with no lows), my OBGYN promised he would put in my chart that I could test using my own meter and administer my own insulin, but failed to do so. The nurses had orders to give insulin as prescribed. There were times when I had to refuse because I knew it would cause a severe low and instead of just calling the doctor and charting it, on 2 occasions the nurses told me I was a terrible mother and non-compiant diabetic! I was not non-compliant, I just was not willing to put myself into hypoglycemia in order to to do what someone had charted. And I was right each time.

Just as I should have been. After all, I've had type 1 diabetes for 36 years, which in effect means I have 314,496 "clinical hours" managing it. I have been blessed to have expert doctors (Donnel Etzweiler from Park Nicolett and later Peter Chase from the Barbara Davis Center for Childhood Diabetes) and am a reasonably intelligent person. But I have repeatedly been treated like I am either uneducated or non-compliant anytime I have questioned the advice of a medical professional, whether in the hospital or anywhere else.

My experience is not unique.

Now I know there are non-compliant patients or those who are working off bad information (the other day my dad-in-law who has type 2 told me his endo told him to eat bananas, but I said he should double check because they're so carb heavy). But the truth is if you take a minute to hear what the patient is saying, you can usually weed out those who are concerned for their health and are trying to share valuable information they know about their disease and those who just don't want to take a shot.

Tatinha · Feb 10, 2014

OP is right. I have seen and have experienced myself all of the misconceptions and really bad information nurses and the healthcare personal have about diabetes. Just to mention a few: patients being offered a lasagna, and a large bowl of carrots with a regular soda for lunch (result: patient was irate and could not comprehend how a hospital could serve such unbalanced diet). pt admitted for nausea, glucose at 170 given dextrose 5% 100 ml/hr.( I understand they are afraid o lows, pt was NPO, but can you just check the sugars more often? result.. sugars went sky high!). another....patient complaining of nausea, type I, sent back home with no work-up. Came back 1 hr later, dehydrated and in full blown DKA. You can beg for a endocrinologist, but nothing is ever done. Although once, I was admitted myself and the doctor told me to keep using my own insulin and sliding scale since they did not have Novolog on the floor(I really appreciate that and give applause's to this smart and nice doctor). That proves not all of our healthcare are stuck in the past of diabetes, or do not understand it.

nursingnow · Feb 10, 2014

As a former Med/surg nurse I would frequently encounter patients angry with hospital policies and how Drs handled their diabetes care. Most Drs would have patients disable insulin pumps during hospital stay and have them on sliding/scale insulin doses, change the times of their doses to where they pretty much had to eat at certain times even if they weren't use to eating at that time. Or they would get meal boluses plus sliding scale and if the patient said it was too much or too little, I would listen and take the concern to the MD. They know their bodies better than me, and I'm not threatened by that in the least! :) I'm glad to see people take such an active role in their care.

lmccrn62, MSN, RN · Feb 10, 2014

Where I work they use high marks rules for glucose control. While I see some benefit but it's only in the hospital then patients go back to their way. It's all about money for hospitals that maintain glucose control.

SHGR, MSN, RN, CNS · Feb 11, 2014

I am appalled at the lack of knowledge surronding care of long term diabetics when admitted to hospital for conditions unrelated ie. heart attack. A friend of mine almost died this week because his BS was allowed to drop to 1.3( canadian ) !!!! not once but 4 times in the span of a week. Long standing insulin doses which these people/or their families have been using/adjusting all their lives are thrown out the window and the hospital staff change up everything including diets etc. CBS are not monitored properly - my friend's wife asked that staff check his CBS when she was there and was told " its not ordered to be checked until 4 hours later". I have also witnessed a hypoglycemic situation being treated with 2 PB &J sandwiches, 2 OJ's with 2 pkg sugar and a banana- so that the patients' BS was then over 27!! How scary is this? These are registered staff - who were supposedly educated or at the very least should have policies and procedures set. What to do??? Family have to almost stay in the hospital and take over this aspect of care.

To translate these blood sugars to th US system (mg/dl) that was a low of about 22 and a high of about 480. The overcompensation by the nurse in that situation is unfortunately all too common- I've seen it both in practice and in the literature.

ButterflyRN90, ASN, RN · Nov 12, 2014

As a former Med/surg nurse I would frequently encounter patients angry with hospital policies and how Drs handled their diabetes care. Most Drs would have patients disable insulin pumps during hospital stay and have them on sliding/scale insulin doses, change the times of their doses to where they pretty much had to eat at certain times even if they weren't use to eating at that time. Or they would get meal boluses plus sliding scale and if the patient said it was too much or too little, I would listen and take the concern to the MD. They know their bodies better than me, and I'm not threatened by that in the least! :) I'm glad to see people take such an active role in their care.

I had an MD shut off my pump. I also had a nurse YELL at me because I bolused for my meal. I really believe there should be classes for nurses on how to deal with pumps and now CGMs. There are many types that are available, but being told to suspend or shut mine off is going to wreak havoc on my blood sugars...

mmc51264, BSN, MSN, RN · Nov 14, 2014

That is why I am on a team that specializes in that. We audit and educate other nurses. We lok at labs and look for trends. I have a son who is Type 1 and I see people all the time not apply critical thinking. I had an order for 6u of Lispro QHS instead of Lantus. No one caught it. Not even pharmacy. Ugh!

SteveDE · Nov 14, 2014

As diabetes educators, we have to realize that our job doesn't "just" deal with educating the patient in how to live with and manage diabetes. Our job is completely diabetes, all the patients I see every day has diabetes, so for the most part 100% of my patient population has diabetes, its not that way in the real world. Other healthcare providers have a 10-20% patient population with diabetes, there job does not "only" include diabetes so they are not going to be as focused and often times not as knowledgeable or up to date. Diabetes is a disease that has had an explosion of new research, new meds, and new tech. stuff that some healthcare workers that don't deal with it on a daily basis are not use to or aware of, it doesn't matter what level of patient care they work with.

Our job as diabetes educators, needs to be patient AND STAFF education. It doesn't matter the initials after their name, we all need refreshed, updated, and educated. Unfortunately, poor diabetes care happens in the hospital, people are sick, physically stressed, emotionally stressed, decreased activity, different meal plan, possibly different meal times, and etc. while in the hospital...and then you have staff to deal with...its the worse place to have controlled diabetes due to about 10 different reasons. More education for ALL, not just patients is needed.

Also, I would like to respectfully say, a heart attack IS related to diabetes. The body and mind are going to be under enormous stress due to a heart attack, that will affect the blood sugar. Diabetes affects the circulatory system, sugar damages the linings of the arteries, creates clogs...there for you have a heart attack. Many times, many, many times, a patient will require a very different diabetes medication set after such a serious event.

Your issues are serious, I would recommend that administration at the hospital be aware of the problems so things can get taken care of properly.

mmc51264, BSN, MSN, RN · Nov 17, 2014

I am not a diabetes educator, but in my unit, ortho, I bet it is closer to 1/3 of our pts are diabetic. The staff, has to be educated. I see the biggest lag in Type 1s even in the residents. They know next to nothing about T1. Or how to treat. I wouldn't mind getting my CDE to be a staff educator.

classicdame, MSN, EdD · Nov 24, 2014

you are right, OP. It generally is not handled in the best manner. It would be impossible for the nurse to know EVERYTHING about EVERY disease. Each diabetic is different. There are all types of oral and injectable meds. Some of the injectables are not insulin. Diets are often changed to accommodate the new critical situation, like post-op, but still there are gaps. I wish there were more endocrine units for patients to be cared for by nurses tuned in to fewer diseases and more expert on this one. Meanwhile, always be a patient advocate. As a diabetic educator I have to watch the MD orders and the nurses care plans to be sure they fit this particular individual and situation. It can be a challenge.