Surveyors often like to look closely at the management of sliding scale insulin…and for good reason. Administration of insulin is a high risk process; one that can be life-threatening if managed incorrectly. During survey, medication safety principles, medical record documentation, as well as the organization’s policies and procedures will be scrutinized.
Complete Order
The order needs to be complete. If you have low, moderate, and high scales, the order needs to specify which scale will be used. If there are options for the type of glucose (Lispro, aspart (Novolog), Humalog) then the type of insulin must also be specified in the order. Sliding scale is often based on the results of glucometer checks. Checks are often ordered before meals and at bedtime (AC & HS) if the patient is able to tolerate meals or every 4-6 hours on a patient with tube feeding. If the patient is maintained on continuous tube feeding, assure that the order is not for AC & HS insulin. Since there are no meal times, the order would be considered incomplete, and a clarification order would need to be obtained and documented. The order needs to include the route of administration. Finally, if a protocol for sliding scale insulin is used, the protocol needs to be ordered by the practitioner, reside in the medical record, and be reviewed annually by the medical staff, pharmacy, and nursing leadership.
The order needs to be complete. If you have low, moderate, and high scales, the order needs to specify which scale will be used. If there are options for the type of glucose (Lispro, aspart (Novolog), Humalog) then the type of insulin must also be specified in the order. Sliding scale is often based on the results of glucometer checks. Checks are often ordered before meals and at bedtime (AC & HS) if the patient is able to tolerate meals or every 4-6 hours on a patient with tube feeding. If the patient is maintained on continuous tube feeding, assure that the order is not for AC & HS insulin. Since there are no meal times, the order would be considered incomplete, and a clarification order would need to be obtained and documented. The order needs to include the route of administration. Finally, if a protocol for sliding scale insulin is used, the protocol needs to be ordered by the practitioner, reside in the medical record, and be reviewed annually by the medical staff, pharmacy, and nursing leadership.
Timing Of Administration Hospital policies and procedures must specifically address the timing of medication administration based on the nature of the medication and the clinical application to ensure safe and timely administration. Insulin is one medication that CMS has defined as a potential time-critical medication. If your organization has defined sliding scale insulin as time-critical by policy, then there is a requirement to administer insulin doses within 30 minutes prior to or after the scheduled administration time. In the case of sliding scale, the 30-minute timeframe would be 30 minutes after the time the glucometer check is performed.
Timing of administration can be tricky with sliding scale insulin based on glucometer checks. If your hospital has scheduled times for meals, then it is easy to determine what time the glucometer checks should be performed, and insulin given. However, if your organization offers concierge meal services and patients are allowed to order their meals at the time of their choosing, it makes things a bit more challenging. The glucometer checks should be done prior to the time the patient chooses to eat. It is vital that staff document the mealtime as well as the insulin administration so surveyors can see that insulin was administered correctly and as ordered. It is wise to encourage the diabetic patient to observe regular mealtimes for control; some facilities have chosen to not allow concierge service on patients with a sliding scale order. The glucometer checks should be performed within a reasonable time of the meal. This may be defined by the organization’s policies and procedures. “Reasonable” could be defined as 30-60 minutes prior to the meal. It is common to see the breakfast glucometer performed at 0500 by the night shift and the breakfast meal not provided until 0730. This would not be considered within a reasonable timeframe prior to the meal.
Documentation
Both the glucose check and the resultant amount of insulin administration (if indicated) must be documented. Where the documentation takes place can be defined by the organization; it may be made on the medication administration record or on a diabetic flow record. If hand-written, “units” must be spelled out each time it is entered. “U” is not an allowable abbreviation, either in an order or in the documentation of administration of insulin. Some organizations require a routine double-check for insulin doses; if that applies to you, assure that you document the double check.
Both the glucose check and the resultant amount of insulin administration (if indicated) must be documented. Where the documentation takes place can be defined by the organization; it may be made on the medication administration record or on a diabetic flow record. If hand-written, “units” must be spelled out each time it is entered. “U” is not an allowable abbreviation, either in an order or in the documentation of administration of insulin. Some organizations require a routine double-check for insulin doses; if that applies to you, assure that you document the double check.
Routine And Sliding Scale Bedtime (HS) Insulin Patients sometimes have an order for scheduled basal HS insulin as well as sliding scale HS insulin. Unless the practitioner has succinctly written to hold one or the other insulins, both doses should be given. Remember that the sliding scale is used to cover the patient’s current glucose level, and the scheduled bedtime dose provides the basal rate. If, in the nurses’ judgement, it would be detrimental to administer both insulins to the patient, the practitioner should be notified for clarification. It is out of a nurses’ scope of practice to decide to hold one of the doses without notification of the physician. For example, the patient has a routine order for 10 units of glargine (Lantus) insulin at bedtime. The patient also has an AC/HS order for Lispro insulin based on the glucose check. The patient’s HS glucose check is 200 which requires coverage of 4 units of Lispro insulin subcutaneous. If the physician has not specified in an order to hold either the sliding scale or the basal insulin and both are indicated, then both would be administered unless the provider is notified, and a clarification order received. Remember that the insulins work differently; therefore, administration of both may be required to manage the patient’s diabetes effectively. Conversely, if the HS glucometer reading does not require insulin coverage, it cannot be assumed that HS basal glucose should also not be given.
Safety is so important when managing and administering sliding scale insulin. Assure that you follow a few basic steps to keep your patient’s diabetes carefully managed.
References
Center for Improvement in Healthcare Quality. (2022). Accreditation Standards for Hospitals.
Centers for Medicare and Medicaid Services. (2020). State Operations Manual, Appendix A – Survey Protocol, Regulations, and Interpretive Guidelines for Hospitals. Section §482.23(c)
Colunga-Lozano, L., et.al. (n.d.). Sliding scale insulin for non-critically ill hospitalized adults with diabetes mellitus.
Center for Improvement in Healthcare Quality. (2022). Accreditation Standards for Hospitals.
Centers for Medicare and Medicaid Services. (2020). State Operations Manual, Appendix A – Survey Protocol, Regulations, and Interpretive Guidelines for Hospitals. Section §482.23(c)
Colunga-Lozano, L., et.al. (n.d.). Sliding scale insulin for non-critically ill hospitalized adults with diabetes mellitus.