4 The adverse clinical consequences of poor glycemic control and its contribution to the hospitalized patient's length of stay are well documented. 2 Over the past 10 years, the Agency for Healthcare Research and Quality reports a 26 percent increase in hospital discharges with a primary diagnosis of diabetes, 3 as coded in the International Classification of Diseases, Ninth Revision, yet glycemic control of hospitalized, non-critically ill patients with diabetes remains suboptimal in most U.S. health care dollars is spent caring for someone with diabetes. In the United States, the prevalence of diabetes mellitus is now 10.8 percent of adults 20 years and older, and 23.1 percent of adults 60 years and older. Changing the sliding-scale insulin culture requires a multidisciplinary effort to improve patient safety and outcomes. Transitions in care require special considerations and attention to glycemic control medications.
Prospective trials have demonstrated reductions in hyperglycemic measurements, hypoglycemia, and adjusted hospital length of stay when physiologic subcutaneous insulin protocols are used. Insulin sensitivity, nutritional intake, and total daily dosing review can alter the physiologic insulin-dosing schedule. This correctional dose resembles a sliding scale, but is only a small fine-tuning of therapy, as opposed to traditional sliding-scale insulin alone. A correctional insulin dose provides a final insulin adjustment based on the preprandial glucose value. The initial total daily dose of subcutaneous insulin is calculated using a factor of 0.3 to 0.6 units per kg body weight, with one half given as long-acting insulin (the basal insulin dose), and the other one half divided daily over three meals as short-acting insulin doses (nutritional insulin doses).
New physiologic subcutaneous insulin protocols use basal, nutritional, and correctional insulin. Evidence for the effectiveness of sliding-scale insulin is lacking after more than 40 years of use. Despite persistent expert recommendations urging its abandonment, the use of sliding-scale insulin remains pervasive in U.S. Glycemic control in hospitalized patients who are not in intensive care remains unsatisfactory.
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