A Little-Acknowledged Danger of Sliding Scale Insulin…

by Flora Bessey, Pharm.D., BCGP
 

Let’s face it: sliding scale insulin (or “rescue dose”) is still very common. This is in spite of the practice being actively discouraged for years, and being listed in the “Beers Criteria” (for years) as a treatment modality to “avoid.” The reasons for this are many, but the main reasons are:

1.    Prescribers want an “intervention” for high blood glucose readings (>150) that doesn’t involve a phone call.

2.    Our patient population, especially in the short-stay Medicare space, is “brittle;” because they are recently discharged from the hospital, their cortisol levels are all over the place with rehab, etc., and they are often only in our facilities for 7-14 days, not enough time to properly gauge an alternative, effective strategy to manage their blood sugars.

So, if we acknowledge that this practice is widespread, and probably is not going away any time soon, we need to be prepared to mitigate the risks associated with it.

As we all know, the orders for sliding scale/rescue dose follow a fairly familiar template: finger sticks 3-5 times per day, with an insulin dose administered based on the blood glucose reading and the physician's’ personal “scale.” But when do these insulin doses get administered? What are the guidelines for administering insulin around meal times?

The answers may surprise and terrify you. For example, what time are your “morning” blood glucose checks administered and who does them? I took a “straw poll” of my facilities, and found that almost exclusively they are done by the night shift, at about 6-6:30 a.m. What was scary was that the night shift was usually administering the insulin dose before they clocked out, based upon the blood glucose reading. It should be noted that with ANY analog bolus insulin (which is the preferred “mealtime” insulin in most nursing home residents), a “meal” needs to be consumed within 15 minutes of a dose to lessen the risk of hypoglycemia. Does anyone think the breakfast trays are consistently being offered in that time window? For that matter, are lunch or dinner trays (or evening snacks) being offered within this time window when blood glucose checks (and subsequent insulin administration) are being conducted throughout the day?

So, what do we do? One strategy I have employed is to encourage my facilities to have the night shift take the blood sugar readings, and note them for “pass-down” with their day shift colleagues. Then, the day shift administers the insulin, which by definition will at least be closer to when the trays are offered. Our goal, of course, should be to make sure we administer insulin in the proper time window, acknowledging that sometimes circumstances interfere (some facilities administer insulin only AFTER a meal is consumed, but that is a topic for another article).

We know how busy our nursing staffs are, and it is an admirable goal to have the night shift “help” the day shift (who are always more busy) by doing the morning “rescue dose” administration, but this is a practice that could lead to unnecessary risk of hypoglycemia for our patients. Some facilities have opted to offer a snack and still have the nurse checking the blood sugar be the one administering the insulin .  What is an appropriate snack if the PI states a meal should be available?  I have heard graham crackers to a half of a sandwich. Neither is a “meal,” but graham crackers are an especially misguided option. If the kitchen was open to make a sandwich, then maybe they could have a tray ready.  The compromise many facilities have settled on is a fruit cup. It can be offered and left at bedside. For residents requiring assistance, the CNA should be informed of the situation. The issue with this strategy is that now the resident’s blood glucose will be elevated at the mid-morning fingerstick. And now we are “chasing” sugars, which is one of the many reasons why the Beers Criteria lists “sliding scale” as inappropriate in our patient population.

If you can do anything, try to understand what is happening at your facility.  Know that if the fingerstick time is scheduled for 6:30 a.m., the nurse has an hour before and an hour after to do the actual fingerstick and give the insulin.  That means a fingerstick may be checked as early as 5:30 a.m. If you have an eager, inexperienced nurse wanting to maximize time, this could present a huge problem….Or we can d/c AM Insulin altogether. Consider a long acting option at HS and give an analog insulin according to sliding scale at 11:30 a.m.  Please evaluate all scenarios at your facility for the sake of patient safety.

For more ideas on how to minimize the risk of hypoglycemia, come to our Summit and hear the presentation on "Lowering the risk of hypoglycemia in persons with Diabetes".

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