Insulin Dosing while hospitalized


(Steven) #1

Since I was diagnosed with T1, I have been hospitalized twice for non-diabetic issues. Once for an infected dog bite and just this week for kidney stones (OMG, they’re painful). Both stays were only overnight.
Both times on admission I told them my usual insulin dose with meals and bedtime. Both times they didn’t give me anywhere near what I told them.

For example: KIDNEY STONE time, when I hadn’t eaten in 24 hours, but my BG was 225 (I assume because of the stress from the PAIN!!!). The nurse Gave me ONE unit of insulin. When I told her that I would normally give myself EIGHT unit in this situation (225 + a low carb hospital meal). She told me she would have to speak to the doctor.
Having gone through exactly the same thing with DOG BITE time, and the disagreement and delay that caused, I didn’t push it. I just used my own insulin that I happened to have. This, of course, is against hospital protocol.

It seems they are using a sliding scale more appropriate for a T2.

Has anyone else had this problem? And how did you address it?


(Dennis J. Dacey, PwD) #2

Actually Steven @sgwilson, I didn’t need to do anything about my insulin dosing other than calculations. Three years ago this month I was admitted through ER on a Sunday afternoon because of an blood infection. At 5 AM on Monday my internist was there to see me and called in the head nurse and told her that all nursing staff was to listen to me about everything diabetes. I ended up staying there nine days.
during this stay, both my internist and endocrinologist suggested that I do my best to “educate” all staff about TypeOne.


(Steven) #3

So, if there is a next time, I should have them get in touch with my Endocrinologist or Internist ASAP?
I guess I assumed that since they are all part of the same hospital system and have access to my medical history, they would listen. I guess i was wrong! Thanks.


(Bill) #4

Yeah, Steven @sgwilson, your endocrinologist/internist “carries you around in her/his head” (well, with a little help from your chart). Once you have developed a several-years-long relationship with a physician, they are your best “insurance” for having your diabetes treated adequately (and well) when you are hospitalized. So, by all means, ask the admitting physician to “request a consult” from your physician. In all likelihood, the hospital doc will turn over management of your diabetes to your physician (and, thus, to you) while you are in the hospital.

And, to tell you the truth, the hospital physician will be very relieved to turn your diabetes over to another “hospital-privileged” physician. T1D can really, really complicate things for the entire hospital staff; having a physician who knows you take over your diabetes care (i.e., the specific orders written in the chart) helps them relax and focus their attention on what caused you to be hospitalized in the first place.

Now, if it’s just an overnight stay, they “may” just try to keep you from starting into DKA. (Some will ask for a quick consult with your physician.) They’ll get you out as quickly as they can and will ask you to follow up with your doc.

Hope this helps.

Bill


(Andy) #5

Did you get to keep the kidney stones?


(Molly) #6

Ugh, this sounds like such an annoying experience! I’ve had it a few times, and have heard from my T1D buddies that they have, too. Hospital staff try to take over the dosing but it often just complicates things. Definitely agree that the best thing is to have them call your endocrinologist. The one time I thought to do that (in the hospital during pregnancy), things went much better!


(Steven) #7

Thanks for the replies. Very helpful. I hope there is NOT a next time, but…
@AJZimmerman, actually Andy, I haven’t given birth yet. I’m still in labor, not sure when the “event” will take place. I’ve been thinking about names. The first and second time I had stones, they were unexpected (like those women on TLC that go to the ER for a stomach ache and leave with a child). Toilecio and Latreno are my elder two. The Urologist today told me that I have four stones, only one of which is in the birth canal. I’m going to name these in honor of the “Flintstones”. I’ll send announcements when “Barney” is delivered. Going to have to figure out what to do with Fred, Wilma and Betty.


(wdshell98) #8

Numerous years ago I had just undergone a radical prostatectomy for cancer. When I was coherent enough to take care of myself I took over because the staff had no idea what they were doing. Thank god my wife was there to also demand my self treatment since I felt so bad and was not getting enough insulin. I always that folks take care of themselves as soon as possible!


(Becky) #9

During my last hospitalization the internist tried to put me on a sliding scale. I just stared at her and asked how they treated T1D with pumps (I was on MDI at the time). She replied that they defer to them and I said that they should do the same with me. She acquiesced and wrote down my “protocol”. Sometimes you need to be the squeaky wheel.
Hospitals are more used to dealing with T2s.


(wadawabbit) #10

I had elective surgery one time, and before they knocked me out I showed them my continuous glucose monitor and my pump, and told/showed them what to do if my numbers rose or fell. They told me they could only accept instructions from my endo! I suppose I could have refused the surgery at the last minute but didn’t want to so I went ahead. I ended up going low and having a nurse screaming my name when I was walking from surgery (with the help of a glucagon injection). Lesson learned for me: have my endo provide written instructions to give to the surgeons or medical staff - apparently some things must be done “doc on doc.” I find it a bit offensive to have to do this, but apparently it’s one of those things you have to do, even though you know your body better than strangers in the hospital.


(Sherri) #11

Yes, I had the same problem.


(Steven) #12

I had no idea how prevalent this problem was!!!
I am an MD! When the nurse delivered my ONE unit of insulin that was ordered per the sliding scale, I reminded her that my body produced NO insulin and that this was inadequate.

Again, I had my pens with me and I wasn’t feeling well, so I did my own thing. Now I know! If I am being admitted, demand that they talk to my endo AND accept nothing less than respect for knowledge of what your body needs.

I will say, Pediatricians are better at this. Shout out to the Pediatricians!!


(Sherri) #13

The second time I was in the hospital, the primary care doc did call my endocrinologist and the issue was resolved. Hospitals tend to use type 2 scales for adjustments.


(Nancy) #14

Hi Steven @sgwilson!

Your high BS was from stress, you are correct. But in addition to pain, being in the hospital, additional/different meds, and the unfamiliar surroundings all contributed. The best protocol is to ask your admitting physician to mark your chart that only YOU treat your diabetes. My surgeon last year suggested that to me because she knew the nurses, PAs, and the on-call docs have no clue how to treat ME.
The only reason I can’t give you a double high 5 for treating yourself behind her back is because if the doc agreed with you, you’d have to fight the nurse to NOT administer the additional insulin.

I hope you are one of the fortunate that only has one episode with kidney stones -

To your good health,

Nancy


(Kristina) #15

Continuing the discussion from Insulin Dosing while hospitalized:

MDs reading posts…how about a teen who manages self-treatment? Is it even an option that the endo will recommend parents/patient take control? I’m thinking of a scenario where we end up with emergency appendicitis or something and can’t get to the children’s hospital that has a diabetes team. Thoughts?


(K) #16

I have had the same problem in the hospital when the doctor is a resident not familiar with diabetes. The scale they use doesn’t count anything else besides the current blood glucose reading.


(Steven) #17

Regarding Kristina’s question;
After reading about other’s experiences, it seems to me that the approach Nancy used (discuss with the admitting physician that you want your chart flagged with your diabetes management instructions) would probably work under most circumstances.
I suppose that a family with a teen that manages self-treatment (and adults with T1) should consider having a discussion with their Endo to have something in writing from him/her that explicitly states that the patient is capable of self-management. Possibly have it notarized and laminated!!!
Then keep such a document with important papers and present it to the admitting physician.
I assure you that I will be having this discussion at my next Endo appointment.

Thanks @Lavallek for the reminder that at teaching hospitals, your admitting physician may be an intern or resident and will have to clear unusual orders with a faculty physician, resulting in delays. We would all be wise to stand up for ourselves in these types of situations.


(Gmkennedy) #18

Sadly this experience is typical for hospitalizations. I have worked in healthcare management for 30 years. My mother-in-Law, husband, son, and grandson all have MODY 10 which is a genetic T1D where they have inherited a faulty insulin gene. Tricky part is their pancreas can still push out insulin from the good gene - whenever it wants. :grimacing:
During hospitalizations for all of them we have had horrible experiences. The hospital staff (nurses and docs) have no clue how to manage this. We have learned to always keep a family member present as when one is not they do what they want and that almost killed my mother-in-Law (dropped her to 35 and luckily my hubby returned and found her - took 24 hours on a glucose drip to get her back). They would not listen to our warning NOT to increase her Lantus as her high BGs were due to them not getting her the Novolog for hours after eating! But they jumped her Lantus by 10 anyway!! Almost killed her. So DON’T leave them alone. Sad, but true. And be demanding. YOU are in control and do not have to take anything they give you. The hospital does not own you. You own You. Stand up for yourself and make sure someone who loves you can do it too if you can’t.


(pamcklein) #19

Hi Steven,

I have had issues as well. I was told one time that the doctors and nurses who work in the hospitals try to keep your BG higher in order to not have to worry about your going low. I was told that the only way around this was if your own doctor told them to do otherwise. As others have said, this is the best thing to do.

I was recently hospitalized (@ 1 month ago) but my situation was a little different. My endo is in another state (I “see” him via phone appointments - - Teledoc). Rather than trying to get the hospital to get in contact with him, I decided to try something. I simply told them in the ER that I use an insulin pump, which is true, and that the only way I would agree to being checked in to the hospital was if they allowed me to continue to use my pump and check my own BGs. I figured if they refused, I would then call my doctor. To my surprise, they agreed! Now, I would not suggest this approach to everyone. In my situation, the reason I was being admitted had no connection to my diabetes, so I figured I had a chance. The staff did still ask about my BGs and I let them know I would let them run slightly higher than my normal to avoid any surprise lows. So, I was actually able to manage my own diabetes during this hospital stay.

Anyway, yes, I have experienced BGs running way too high due to hospital staff wanting to avoid low BGs. In fact, another time, I was given steroids and told them what I would normally take, like you, only I ended up in the ICU because the “couldn’t” get my BG below 500mg/dl! They admitted the doctor on staff was worried that if he gave me what I told them to I would drop.
I think this is a pretty common problem, especially for Type 1’s. While I can understand the hospital reasoning, I personally think they take it too far and keep the BG higher than is necessary. Then again, I am very sensitive to insulin, so what might work for some, would affect me more. Still, I think hospital staffs in general need to listen to their patients more.
That’s just my experience and opinion though!

Pam K.
T1D 54 yrs. and counting!