Do NOT Touch the Insulin

Perhaps I’m biased, but it seems to me that more errors occur in the hospital in the management of diabetes than with any other disorder. Approximately 40% of hospitalized patients have diabetes. As an endocrinologist, I see a very small fraction of these patients. And yet, almost every other day, I see it mismanaged.

Patients who are on insulin at home have their basal insulin and their premeal doses held on admission, and they are put on a scale alone. This has led to the development of DKA during the patient’s admission. Or, patients who were on sulfonylureas at home, are kept on them even in the face of renal failure or poor PO intake. This leads to hypoglycemia. Or, patients are having glucose readings of 300 for days without any medication adjustment. Patients on insulin pumps are being told to remove their pumps even if they are awake and alert and perfectly capable of managing the pump in the hospital.

Even after I am consulted, my orders are either ignored by nurses or changed by other physicians. If the patient is made NPO, the basal insulin is held, sometimes with another doctor’s order, but sometimes without one. If the patient’s premeal glucose is 80, the prandial insulin is held because it is “not necessary.” And this is despite order sets and protocols that clearly state which insulins are to be held or not held and under what conditions. I don’t see staff or other physicians changing chemo orders or dialysis orders. They don’t even touch anticoagulants without checking with cardiology first. But insulin? Oh sure, that they can mess with. And this is not isolated to the hospital I am at now. This was a problem in the hospitals I worked at before. It happens in nursing homes too.

I am currently part of a committee that is trying to improve the order sets and protocols in our hospital. This includes nursing, physician, and patient education. If more than a third of hospitalized patients have diabetes, and uncontrolled diabetes has an impact on hospital stay and on patient morbidity and mortality, it is imperative that improvements in patient care be made.

Have you had similar experiences? How have you tried to instigate change?

Disclosures:

Melissa Young, MD, FACE, FACP, is an endocrinologist in private practice, an assistant clinical professor at Robert Wood Johnson Medical School, and a working suburban mother of two in Freehold, NJ.