Question regarding safe medical practice

[LPN wny]

Hi. I'm seeking advisement regarding a situation I am currently in. Previous work history for me includes home health management of patients with diabetes and hundreds of diabetic management visits where I would check blood sugar and administer insulin if ordered to said patients.

The current situation. I work in a facility. I find the following situation questionable. The situation is this: I take care of an individual who is a brittle diabetic. The individual gets a set dose of short acting insulin three times a day. A set dose of long acting insulin once a day in the morning and one blood sugar check in the morning with short and long acting insulin doses. There are no other blood sugar checks for the individual with the other insulin administration's for the individual, or at HS, just one check in the morning. We can check the individuals blood sugar if there are signs of hypo or hyper glycemia, however this individual is DD, and it is virtually impossible to detect hypo or hyper glycemia with the individual due to behavior issues. Also, the checking of the individual's blood sugar other than at the ordered time is frowned upon, and there is basically no one other than I and another nurse that would quote on quote know enough to check a blood sugar if something was going on with this individual.

Is this situation medically safe? Does this follow common medical practice? I am told that the orders we have cover the situation but my feeling is it's medically unsafe and doesn't follow common medical practice regarding diabetes management.

Any advisement would be appreciated. Thanks for your help!

[oceanblue52]

I personally would never administer insulin without checking a blood sugar, that in and of itself should be reason enough to get the policy changed.

[LPN wny]

Thanks for the input, I appreciate it. I agree with what you said. Regarding my concerns, I have also spoken with other parties both nursing and non nursing outside of the situation and they agreed that the situation doesn't seem medically sound.

Apparently, PRN checking of the blood sugar is now frowned upon for the individual. Basically if I hadn't been checking blood sugars on the individual under the PRN guideline the individuals blood sugar would generally only be checked at the one time that it is ordered for, and not checked otherwise.

Regarding policy change, it's my opinion vs the company's medical staff and the other medical staff at the facilities opinion. That being said I don't believe I'm going to have any luck with getting the policy or order changed for the individual.

Thanks again for your input.

[oceanblue52]

But aren't you administering insulin multiple times a day? Checking a blood sugar before a scheduled medication should not count as a "PRN" accucheck. Have you talked to the doctor? I would just tell said provider that I will not be administering insulin unless you change the order to include accu-checks with every insulin administration. If they are not willing to change it I would either refuse to take that assignment or find a different job. Insulin is a high risk medication and especially for Type 1 Diabetics, there should be strict glucose ranges for when to administer and when to hol.

It sounds like you know all this already, but I would consider the fact that you will be the one accountable if you give the patient insulin and he or she bottoms out. If the provider and/or nursing director is not understanding this, you should consider looking for another job, for the sake of the patient's safety and your license.

[Here.I.Stand, BSN, RN]

And aren't "brittle diabetics" by definition prone to lows?

[LPN wny]

Oceanblue52, thanks for another response. I appreciate it.The situation makes no sense and that's why I'm uncomfortable with it. Essentially where I work you are working in a pretend world made for said individuals and the pretend unrealistic world has now extended to the medical management of an individual at this point. I agree with everything you've said. In short the individual is improperly managed. The facility cannot manage him properly due to their policies and so they are ignoring proper medical practice because they physically can't deal with him. I would guess he has dementia and or some level of psychological irregularities going on. It's extremely difficult at best to do anything with him out of routine so further evaluation of his mental status is difficult at best. As such the company and medical persons in the company managing his care have decided to ignore proper medical management and or discontinue proper procedures which would be in place if they were to follow common medical practice. It's out of my hands, consequently I am extremely uncomfortable with the situation and am looking for other employment.

[LPN wny]

Hello and thanks for your response. Yes that would be my understanding of brittle diabetics as well. There is no way to predict what their blood sugars will be. Could be high, or low, or 580 or 29; at any time of the day. That's why you check their blood sugars frequently. My guess regarding the situation is the medical staff and ordering doctor(?) here are ignoring that the whole situation is medically unsafe... or the management people involved are very sheltered and don't know what they're dealing with. I'm going with the first guess.

Thanks again for your response.