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Twilight of the Sliding Scale

Anticipatory Use of Insulin in the Hospital

The components of anticipatory subcutaneous insulin order-writing have been described according to preference of several authors (having basal, nutritional, and correction components). But in the hospital no style has been validated as superior to any other.34-37 The anticipatory delivery of nutritional insulin must match the expected pattern of exposure to carbohydrate. Specific standing orders should include additional nursing directions such as “do not withhold” or “hold if NPO.” For abrupt discontinuation of carbohydrate exposure, change of organ function, or decline of insulin resistance, protections must be in place to guard against hypoglycemia.38

An essential aspect of management is the frequent review of orders for subcutaneous insulin and patient response. At least once every day, the caregiver must reconsider “today’s insulin dose.”

How to Get Rid of Sliding Scale

Computerized order entry for managing hyperglycemia now is widespread among hospitals. Under a misdirected allocation of resources, motivated by concern for quality and safety, institutions have embraced the programming of order-entry options for standardized sliding scales. The sliding scale menu may provide a quick link to order entry for point-of-care blood capillary glucose monitoring, call parameters, and treatment of hypoglycemia. Nurses and doctors may come to believe that it is impossible even to order blood glucose monitoring without an accompanying sliding scale. Thus the sliding scale menu may possess all the accoutrements of glycemic management program except the one element most needed—a provision for anticipatory insulin.

One study by Achtmeyer and colleagues reduced utilization of a computerized sliding scale order by attaching a warning that the order was not approved by endocrinology.39 Emphasizing the importance of physician education to the successful abolition of sliding scale insulin, the study by Baldwin details an intensive house staff re-education program on how to write anticipatory insulin orders.32 The computerized order entry options used at Rush University Medical Center in Chicago (one of the two better performers in the recent benchmarking study of the University HealthSystem Consortium) were presented by Baldwin at the Aug. 19, 2005, “Glycemic Control Knowledge Transfer Meeting of the Consortium in Chicago.”

Why has use of the sliding scale persisted in practice? Is it for fear of hypoglycemia? Is it for lack of evidence on the importance of glycemic control? Even before computerization was sliding scale the path of least resistance? Is it because no clear superiority has been demonstrated among various styles of writing anticipatory insulin plans? Is it because physicians do not know how to write insulin orders? Or is it all in a name?

It just might seem that ordering sliding scale is the easy thing to call for or is the sophisticated thing to order. After all, sliding scale is an in-group term. A newly graduated physician is not likely to reject the suggestion of an experienced nurse that an order is needed for sliding scale.

For the next 50 years what is the call for, and what are the orders? Quite simply we have seen the twilight of the sliding scale—and “today’s insulin” dawning. TH

Dr. Braithwaite is clinical professor of medicine at the University of North Carolina, Diabetes Care Center, Durham.

References

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