I have surgeries for broken fibia, and three on my back. All at the hospital where my diabetologist works. He has placed a letter in my chart stating that “Patient controls his insulin dosing.” When I go in I request the PA covering for endocrinology meet with me, point out the note, and have her talk to the staff. O.N. stays the PA will check with me daily and resolve issues. When I was in the ICU for 10 days, the medicine people came in and insisted I allow them to use their IV pump and sensor, insisting their algorithm was better. I was curious, and negotiated that we would try it for one day; well, after 1 day with my BG above 250 they let me reconnect my pump and self regulate.
I have never had a problem with my pump or cgm working during surgery. I have asked them to place my phone in a baggy (so they can wipe it down with disinfectant) and show them they can press the power button and have my cgm data show on my lock screen. They still did finger sticks. I also tell them that I set my pump to 50% of normal basel, and they are fine with that.
To illustrate the performance of sensors during surgery, individual-level data are presented for patients 1–8 in Fig. 1C and D. We observed that sensors were accurate before surgery; however, intermittent signal loss was common during the operative course. After surgery, some sensors maintained precision (following POC patterns in parallel [Fig. 1D]) but lost accuracy (predominantly negative bias), particularly those with longer signal gaps. Six sensors recovered accuracy after surgery (within 20% of reference values). Sensors that recovered accuracy maintained reliable readings despite vasopressor therapy (Fig. 1B). We did not observe differences in complications, length of stay, or transfusions between patients wearing the recovering devices and those wearing nonrecovering devices.
In Sept past I was admitted to a rehab Hospital for femur a pelvis fractures. They too were using is sliding scale. It took me making a call to my Endo Doc. to get them to use not only my own brand of insulin . And dose myself.
Being an inpatient with T1D is my worst nightmare. The hospital I have to use (HMO) requires that T1D patients give them our pumps, CGM’s and glucose monitors. They use the sliding scale - using R insulin! And the target bg is 180! These policies come from the head of the HMO Endo Dept!. As someone who aims for TITR (70-140) the Endo-in-charge always makes sure I have paper copies of their inpatient policy.
The HMO policy is 4-6 fingersticks a day (that’s all!) and they use a One Touch monitor - which I cannot use safely (The Diabetes Tech Society, the AACE among other studies have shown that the One Touch reads higher than actual on patients with chronic anemia. Perhaps that will work out for me since their target of 180 will appear on a One Touch when I am at a bg of 120).
I’ve tried to cite Recommendation 7.27 in the 2023 - 2025 Standards of Diabetes Care. That recommendation states that inpatients with T1D who are conscious, and show the ability and capacity to manage their own T1D should be allowed to so. I’m already looking for a new Endo (and of course that means new health plan, new Primary for the referral to Endo etc)
So no long-acting insulin? As I said, there are 2 court decisions against Mass General and Brigham and Women’s for this kind of negligence. Death and permanent brain damage from insulin overdose.
Even if hospitals use a long-acting (Levemir, Lantus) they assume a flat deliver of insulin action when many people don’t have a “flat need” for basal insulin. At the very least, hospitals should look at the personal basal profiles (I have 9 time zones in my pump - each with its own basal rate, correction factor - ISF, and correction factor). And using R insulin via IV can also be a disaster. R insulin action is delayed, so it is a game of catching up - overall, not very effective.
Often, the excuse for not letting YT1D patients keep there devices and be in control of their T1D mgt is that “the devices are too complex” WTF! Just look at all the telemetry devices nurses handle. And let’s face it not all ped T1D patients have parents who are MD’s and most patients with T1D aren’t MD’s either. MD!
Negligence not to review readily available patient records for this information and follow it to the letter, calling endos as necessary. Why else were medical records digitized?
When you all are talking about sliding scale, do you mean like regular insulin and NPH.
Because it’s difficult to wrap my head around that.
Because carb counting could be called a sliding scale to an un informed person.
Or anything that takes into account of blood sugar and carb intake at the time of dosing.
I really don’t understand why a hospital would choose outdated methods, at the same time, I understand they don’t want you to have tight control because they don’t want hypos.
It’s true you will be fine at 180 for a few days, but I just prefer to not.
If some nurse took my insulin from me, there would be a fight and then I would just get more.
It’s like you are talking about diabetes in the 1980 s when I hear your stories.
It seems to ignore long acting altogether. That’s a constant. It may make sense for some people with Type 2. Nurses would like to force it onto Type 1 patients.
Ok so I found a study from 2017 that compared the sliding scale to basal/bolus strategies while having a short hospital stay
When you see the data it makes perfect sense why hospitals prefer sliding scale.
From a clinical perspective it is much safer, however if I was running high every day and up and down on a sliding scale, I’m pretty sure I would be anxious and uncomfortable.
I still will prefer to do my own thing.
Doctors and hospitals will do the thing that has least amount of acute events. It’s just how it is Sliding scale insulin for non‐critically ill hospitalised adults with diabetes mellitus - PMC.
@Sue_R makes a good point. Sliding scale insulin (SSI) therapy can serve some T2Ds reasonably well but definitely discriminates against the fundamental metabolic needs of T1Ds. The lack of basal insulin can be tolerated OK by a T2D whose pancreas still secretes some basal insulin. At least it works well enough to protect against deadly DKA.
Hospitals and overburdened doctors benefit from SSI therapy because it standardizes insulin dosing orders and relieves the doctors from having to calculate doses based on individual metabolic needs.
T1Ds, unfortunately, see their health and safety materially compromised when a hospital uses an SSI system. In essence, they completely dismiss the short term interest of T1Ds because they comprise a distinct minority of diabetics. It’s the reason that many of us quickly sense the lack of knowledge of hospital medical professionals when it comes to the actual different metabolic needs of the 10% of the diabetic population T1Ds versus the 90% of the diabetic population T2Ds.
I argue that the SSI system is good for no-one and is a remnant of a previous era. If an honest measurement of extended hospital stays, number of infections, and added burden on the system caused by hyperglycemia were ever published then we might see a move to forever banish the unhealthy unsafe SSI regimen.
I will choose to sustain my hospital insulin autonomy for as long as I am cognitively and physically able. I genuinely fear the day that I must endure hospitals taking over my insulin dosing job. When that happens, I fear that my days truly numbered. I accept that I won’t live forever; what I can’t accept is that the health care system could cause my early demise based on ignorance and incompetence.
I know there are a minority of great providers in the system and I can only hope to fall into their care when the time comes.
We are not as prone to DKA but just as dangerous hyperosmolar hyperglycemic state (HHS).
HHS has high BG, excessive thirst with a lack of ketones. Usually brought on by inadequate or lack of enough insulin.
SGLT 2 inhibitors Farxiga, Jardiance and Invokan,combined with general anesthesia is a definite cause of DKA in those with T2DM. It happened to one of my sons.
HHS has a mortality rate of 20% with DKA ranging from 1.2 to 9%.
The thing is we are all at risk from poor hospital protocols.
There is most certainly a place for sliding scale (fast acting no basal on-board) blood glucose control when a diabetic is in the hospital setting. When it wouldn’t be needed is when a patient is on a pump, fully capable of managing the hardware, and wants to stay in charge of their diabetic care. This was acceptable protocol at the large teaching hospital I worked at for 35 years. But, if someone was taking large doses of narcotic, is in any way not fully alert and cognizant of their status, or their illness is causing a labile or unpredictable blood glucose, then it makes sense for the staff to monitor and dose the patient.
Think of it this way - if you were so out of it that it would be criminal to drive a car then you probably shouldn’t be giving yourself insulin while sick in the hospital setting.. Could the target range most doctors feel comfortable with be lower? Absolutely, especially since we know high blood sugars slow surgical healing. Personally, I seldom had to dose with a sliding scale as the patients I worked with in the ICU setting were on IV insulin drips where you could adjust insulin doses that had a five minute duration of action.
So, I agree there are circumstances where patients would do very well directing their own insulin deliver. But, more often than not, that would be risky given typical in-patient hospital acuity levels.
For myself, I have trouble imagining how to adjust my basal rates if I was lying on my back on a hospital bed eating those meals on a tray 24/7. Even if a hospital “allowed” me to continue managing my pump I expect it to be a struggle.
Yep, when someone gets the standard 1200 calorie ADA diet - it’s setting the patient up for trouble. It’s just wrong for most people on insulin therapy. Slowly, food as adjunct therapy is becoming a thing.
@Sue_R I am sorry you had such a terrible experience. Sliding scale is not a one-size-fits-all order. It is indeed customized for patient sensitivity and in your case it sounds like the order was incorrect. I can understand your anger and mistrust going forward - I’d feel the same way.
