Range insulin dosage versus sliding scale

[michael79]

My facility would like to move away from ss insulin. I used to work at a hospital where the MD would write orders for range dose insulin. I cannot remember the ranges though. Can anyone help me?

[*ac*]

Depends on the patient and their sensitivity to insulin.

[michael79]

I'm asking for an example so that I can show it to someone at our corporate office. I know that it is different for everyone.

[*ac*]

Oh, sorry, I don't have an example.

Just wondering, who will do the exact calculation of the dosage within the range?

At my hospitial, we don't use sliding scale, rather each dose is calculated using the patient's formula, then the order is entered for each dose. The resident MD does the calculation, has it checked by the attending, then puts in the order for nursing. After that, the nurse draws up (or dials if using a pen) the dose and has it double checked by another RN.

So, what I'm saying is we have at least 4 people reviewing each dose, because insulin is considered high risk.

Using a range-dose order seems to imply that nursing will do the calculation. I would think the order would be written something like, give 1 unit of Novolog per 50 mml of blood glucose over 100 mml of blood glucose, plus 1 unit of Novolog per 50 grams of carbohydrate to be eaten, plus 5% of total daily dose for small ketones.... up to some arbritrary max dose. This is how the calculation is done (the sensitivity and carb ratio individualized). However, I know that some places, including mine, consider doing this calculation outside the scope of RN, because they consider it presciptive.

[michael79]

Wow! That is complex! The orders were something like

For BS:

200-250: Give 2 units Novalog

250-300: Give 3 units NOvalog

300-350: Give 4 units Novalog

350-400: Give 5 units Novalog

For BS > 400: Call MD

[*ac*]

Wow! That is complex! The orders were something like

For BS:

200-250: Give 2 units Novalog

250-300: Give 3 units NOvalog

300-350: Give 4 units Novalog

350-400: Give 5 units Novalog

For BS > 400: Call MD

How is that different from using a sliding scale?

[WSU_Ally_RN, BSN, RN]

maybe you can consult with an endocrinology department? I'm sure they could give you more insight to something like that...

[michael79]

Sliding scale is typically bs-100/30 or some variation on that. We are trying to get our med tech's away from doing the math that is involved as it can lead to a great incidence of errors.

[*ac*]

I think this is a difference of terminology. The diabetes educator core curriculum describes a table, such as your example, as a "sliding scale". If you google "sliding scale" you'll get lots of examples of what you're looking for.

[blondy2061h, MSN, RN]

Oh, sorry, I don't have an example.

Just wondering, who will do the exact calculation of the dosage within the range?

At my hospitial, we don't use sliding scale, rather each dose is calculated using the patient's formula, then the order is entered for each dose. The resident MD does the calculation, has it checked by the attending, then puts in the order for nursing. After that, the nurse draws up (or dials if using a pen) the dose and has it double checked by another RN.

So, what I'm saying is we have at least 4 people reviewing each dose, because insulin is considered high risk.

Using a range-dose order seems to imply that nursing will do the calculation. I would think the order would be written something like, give 1 unit of Novolog per 50 mml of blood glucose over 100 mml of blood glucose, plus 1 unit of Novolog per 50 grams of carbohydrate to be eaten, plus 5% of total daily dose for small ketones.... up to some arbritrary max dose. This is how the calculation is done (the sensitivity and carb ratio individualized). However, I know that some places, including mine, consider doing this calculation outside the scope of RN, because they consider it presciptive.

I'm glad your hospital is doing it that way, as it's a much more precise and safe way of doing things. So you call the attending for a dose every time you need to give insulin? That seems a little odd. That's no more complex than titrating a drip, which is well within an RN's scope of practice. I have type 1 diabetes, and that is pretty much how I calculate my doses.

[*ac*]

I'm glad your hospital is doing it that way, as it's a much more precise and safe way of doing things. So you call the attending for a dose every time you need to give insulin? That seems a little odd. That's no more complex than titrating a drip, which is well within an RN's scope of practice. I have type 1 diabetes, and that is pretty much how I calculate my doses.

I guess there have been enough mistakes in the past that the endo attending wants to walk through every dose with the residents (which change every couple of months) and nursing wants to cover itself. It's incredibly time-consuming.

[classicdame, MSN, EdD]

Ask your pharmacist or the mfg. rep for the medications on your facility's formulary. The rapid acting insulins may be given as a specific dose at meals with a correction dose added as needed. This varies widely. There is no "one-size-fits-all" like sliding scale. That is the reason sliding scale is considered obsolete. Patients and their situations vary considerably.