Sliding Scale-when to discontinue

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whopper

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Simple question, but I've been out of IM for some time (I'm in Psychiatry)

You got a patient which for all intents & purposes is believed to be medically stable, but is admitted to the Psychiatric ward with a history of diabetes.

I always put such patients on sliding scale insulin. While we're told that they are medically stable, ER doctors often do not order HGB A1C's and often aren't concerned with blood sugar values less than 300. Further, psychiatric patients often have poor self care and poor cognition. They don't worry about these things. You're concerned about the psychiatric presentation usually more so than the medical concerns, but you have to be mindful of any problems that can happen medically. ER docs that clear these patients often miss important things.

Anyways, at what point is it alright to discontinue the sliding scale that is considered "standard of care". If the pt's blood sugars have been normal for some time--say 24 hours--and they seem to be diet controlled or controlled on the diabetic medications they are already on--when is it safe to discontinue?

Often times these patients can be agitated and fingersticking them isn't exactly something you want to do if it can be avoided.
 
I usually consider the inpatient psychiatric unit to be an outpatient setting from a medical standpoint. (no offense to the psychiatrists -- it is definitely an inpatient psych setting, but the patients there usually don't have any acute medical problems.)

So because I think that these patients should be treated medically as if they are outpatients, I don't feel like it is necessary to have them on sliding scales at all if they are not normally on insulin at home. You are not going to have any acute problems with someone who has elevated blood sugar, as long as the sugars aren't too high (too high being somewhere above 300, which is usually the cutoff where our ER gets excited as well). All of this is chronic management, and it is safe to let their sugars run moderately high while you are working on getting them down with po meds over the short term setting (short term defined as a period of weeks to months). This is all assuming they're not infected or s/p surgery or something -- those are the times you need to get the sugars down faster.

Now I understand that a lot of these patients are unreliable, and you might not know what they are taking as outpatients (they may tell you one thing and be on something different), so I see nothing wrong with checking fingersticks on them for a day to make sure they're not hypoglycemic on the meds you're giving them, but if everything looks okay, you could probably cut the fingersticks to, say, 3x/week. And you really don't need to have sliding scales at all -- just adjust their po meds over time. Of course, if someone is on insulin at baseline, then they need to be checking much more frequently.
 
"I usually consider the inpatient psychiatric unit to be an outpatient setting from a medical standpoint. (no offense to the psychiatrists -- it is definitely an inpatient psych setting, but the patients there usually don't have any acute medical problems.)"

Not an unreasonable approach. For all intents & purposes, most inpt Psychiatric pts are medically stable. They're not supposed to be put into the unit unless they are stable.

However, and just as you point out--many psychiatric pts are unreliable, and many ER docs or docs covering the floors want the pt out, sometimes not considering the lack of ability to care for these pts in a psychiatric unit (for example we can't give IV lines).


I did have one patient who's BSR was over 300 while on the inpt unit. Yeah he was one of those "once a year" rarities, but it happens. Turned out his mental illness was so bad he had no insight on his need for insulin. Schizophrenic pts with poor compliance with psychiatric meds, if they also have diabetes have a poor prognosis in both diseases.

Thanks for the input!
 
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