References as promised after last week's Board Review Series... sorry for the delay... so, check out the recent consensus statement and the supporting articles, whose titles say it all... let's all stop using SSI alone... jbwMD
"the persistent overuse of what has been branded as sliding scale insulin (SSI) for management of hyperglycemia. The term "correction insulin," which refers to the use of additional short- or rapid-acting insulin in conjunction with scheduled insulin doses to treat blood glucose levels above desired targets, is preferred. Prolonged therapy with SSI as the sole regimen is ineffective in the majority of patients (and potentially dangerous in those with type I diabetes)."
"Suboptimal glycemic control is common in medical inpatients with diabetes mellitus. The risk of suboptimal control is associated with selected demographic and clinical characteristics, which can be ascertained at hospital admission. Although sliding scale insulin regimens are prescribed for the majority of inpatients with diabetes, they appear to provide no benefit; in fact, when used without a standing dose of intermediate-acting insulin, they are associated with an increased rate of hyperglycemic episodes."
... contains nice examples of order sets for Insulin Infusions and Basal Bolus Insulin Orders.
"Medical history, blood glucose, and HbA1c testing can effectively identify patients with inpatient hyperglycemia. Using direct ward-based teaching and a widely disseminated pocket set of guidelines, house officers can be taught to effectively and safely manage inpatient hyperglycemia without the use of SSI."
"Inpatient hyperglycemia in people with or without diabetes is associated with an increased risk of complications and mortality, a longer hospital stay, a higher admission rate to the intensive care unit, and higher hospitalization costs. Despite increasing evidence that supports intensive glycemic control in hospitalized patients, blood glucose control continues to be challenging, and sliding scale insulin coverage, a practice associated with limited therapeutic success, continues to be the most frequent insulin regimen in hospitalized patients. Sliding scale insulin has been in use for more than 80 years without much evidence to support its use as the standard of care. Several studies have revealed evidence of poor glycemic control and deleterious effects in sliding scale insulin use. To understand its wide use and acceptance, we reviewed the origin, advantages, and disadvantages of sliding scale insulin in the inpatient setting.
"In most teaching hospitals in the United States, primary care first-year residents and medical students learn about sliding scale insulin (SSI), usually from a senior resident. The more experienced resident explains how to prescribe regular insulin every 4 to 6 hours without any scheduled basal or mealtime (prandial) insulin. For the typical patient who is too sick to eat, this results in a roller coaster effect on blood glucose variability due to poor matching of insulin with individual blood glucose patterns. Unfortunately, for the patient who is able to eat, insulin scheduled to be administered based on a bedside capillary glucose measurement is actually administered long after the meal is consumed. Although there are often challenges with hospital logistics in terms of timing of insulin administration in relation to actual food intake, the SSI orders typically do not mention the relationship of the insulin injection as it pertains to a meal, even though at one time, the resident was taught that regular insulin is mealtime insulin. Even worse, SSI, as used here, does not account for the basic principles of insulin therapy.
"Medical professionals do not use sliding scale penicillin for fever or sliding scale oxygen for pulmonary edema. It is time to discontinue amusement park diabetes therapy so that decades from now clinicians are still not trying to abolish an illogical treatment. Perhaps next July or the following summer, when the senior resident is explaining to the intern hyperglycemia management for a newly admitted patient with pneumonia, the discussion will revolve around basal insulin, prandial insulin, and correction-dose insulin based on a protocol that all hyperglycemic patients receive throughout the entire health care system."