Running head: SLIDING SCALE INSULIN AS A METHOD OF GLYCEMIC CONTROL
Sliding Scale Insulin as a Method of Glycemic Control
Joella M. Show
Ferris State University
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SLIDING SCALE INSULIN AS A METHOD OF GLYCEMIC CONTROL
Abstract
I formulated a PICO question that asks about whether sliding scale insulin is a safe and
appropriate method of glycemic control. The purpose of this article is to state my PICO
question, state the purpose of nursing research, and provide information from research articles
the answer my PICO question. I then give a recommendation to improve quality and patient
safety for the non-critically ill hospitalized adult patient that requires insulin to manage their
blood sugars for glycemic control.
Keywords: sliding scale, glycemic control, patient, hospital, PICO, basal-bolus, insulin
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SLIDING SCALE INSULIN AS A METHOD OF GLYCEMIC CONTROL
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Sliding Scale Insulin as a Method of Glycemic Control
The purpose of this PICO paper is to state my PICO question and how I was able to
support the answer to my PICO question with nursing research that a can be used for evidence
based nursing practice. Leaders in nursing practice use research to support their nursing practice.
There is a formal way to communicate this research to other nurses. Using nursing research for
evidence based nursing practice with improve quality and safety in patient care.
PICO Question
A PICO question is a clinical question that has been formatted to help a professional
determine an evidence based answer for the clinical question. According to Stillwell, FineoutOverholt, Melnyk, and Williamson (2010) the acronym PICOT stands for “patient population
(P), intervention of interest (I), comparison intervention of interest (C), outcome(s) of interest
(O), and time it takes for the intervention to achieve the outcome(s) (T) (p. 41). I chose to leave
out the (T) that represented time so my clinical question is a PICO rather than a PICOT question.
My PICO question addresses sliding scale insulin, glycemic control, basal-bolus insulin
and patient safety in the non-critical hospital setting. In the non-critically ill hospitalized adult
population with Insulin Dependent Diabetes Mellitus (IDDM), how does administering sliding
scale insulin therapy improve glycemic control when compared to administering a basal-bolus
insulin regimen? This question would also apply to patients on steroids who require insulin to
regulate their blood sugar levels.
It is important for nursing research to be shared within the nursing community
(Nieswiadomy, 2013). The results of research studies are often published in research and clinical
journals or presented in lectures (Nieswiadomy, 2013). Nursing leaders can share nursing
research within the nursing profession through reports, conferences, papers, and posters
SLIDING SCALE INSULIN AS A METHOD OF GLYCEMIC CONTROL
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(Nieswiadomy, 2013). As a student of Ferris State University (FSU) I have access to a large
number of nursing journals in the Ferris Library for Information, Technology, and Education
(FLITE). I am able to access nursing research through the FLITE library. I can share this
research with my coworkers and manager in the hospital where I work. I can also use the
research articles on the FLITE library to answer my PICO question.
Research Findings
Using the FLITE library research database I was able to complete several searches within
CINAHL and PUBMED. I used the words sliding scale, glycemic control, patient, and hospital
in the search engine to help narrow down the research findings. I only chose research literature
that was less than five years old. Four articles stood out to me as appropriate for use in answering
my PICO question.
The first research article is a Retrospective Analysis. It is a Randomized Controlled Trial
which is a level II in the hierarchy of evidence. This study included 331 participants. There
were 121 patients in the control group who received a sliding scale (SS) insulin regimen and
there were 210 patients in the experimental group who received a basal-bolus insulin regimen.
The study concluded that patients who were treated with the basal-bolus insulin regimen
“experienced more blood glucose measurements in the target range as compared with patients
treated with SS with relatively low hypoglycemia rates” (Patel et al., 2009, p. 1774).
The second research article is a Randomized Controlled Trial which is a level II in the
hierarchy of evidence (Schroeder et al., 2012). This study included a small sample size of 30
participants in the control group who receive a sliding scale insulin regimen and 35 participants
in the experimental group who received a basal-bolus insulin regimen. The study found that the
SLIDING SCALE INSULIN AS A METHOD OF GLYCEMIC CONTROL
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intervention group had improved glycaemic control, shorter hospital stays, and that it was easier
to follow the basal-bolus insulin regimen (Schroeder et al., 2012, p. 71).
The third research article is a Randomized Multicenter Trial which is a level II in the
hierarchy of evidence (Umpierrez, 2011). This study uses an appropriate sample size of 211
participants. These participants are divided almost equally into a control group that receives a
sliding scale insulin (SSI) regimen and an experimental group that receives basal-bolus insulin
coverage regimen for control of their blood sugar. The study concluded that “basal-bolus
treatment with glargine once daily plus glulisine before meals improved glycemic control and
reduced hospital complications compared with SSI in general surgery patients”(Umpierrez, 2011,
p. 256).
The fourth research article is a level I in the hierarchy of evidence (Shaw, 2009). This
article is also specifically nursing research that systematically reviewed six studies and evaluated
them “using the American Diabetes Association (ADA) system for evidence ranking” (Shaw,
2009, p. 1). The result of the systematic review showed that “Five out of the six studies
substantiate the current clinical practice guidelines that conclude SSI as primary treatment for
hyperglycemia is ineffective and unreliable” (Shaw, 2009, p. 1).
After reading several research articles (Schroeder et al., 2012; Umpierrez, 2011; Shaw,
2009; Patel et al., 2009) that compared SSI and basal-bolus insulin from level I & II on the
hierarch of evidence for intervention studies (Stillwell, Fineout-Overholt, Melnyk, &
Williamson, 2010), I am convinced that a basal-bolus insulin regimen is more appropriate than
the sliding scale insulin regimen for glycemic control of the non-critically ill hospitalized adult
patient.
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Recommendations to Improve Quality and Safety
According to the Standard 1 in the Scope and Standards of Practice written by the
American Nurses Association (ANA) it is my responsibility as a professional nurse to check
blood sugar levels and administer insulin therapy as ordered by my patient’s doctor (ANA,
2010). As a nurse I am concerned with the safety of my patient as I attempt to regulate their
blood sugar according to the doctor’s orders. It is my responsibility to learn about evidence
based nursing research and then to apply this evidence in my nursing practice in order to provide
the most safe and excellent care possible for the good of my patient.
I do not have the ability to directly change how I administer insulin to help maintain
glycemic control for the patient I am taking care of. Standard 13 directs a nurse to collaborate
with other medical professionals regarding patient care (ANA, 2010). If I become concerned
that the hospital was not providing excellent patient care in regards to glycemic control because
they were only using a SSI regimen rather than a basal-bolus insulin regimen for their IDDM
patients then it would be appropriate for me to take this information to my manager and to the
director of quality and safety for the hospital. I could ask them what their suggestions were for
making this research based evidence about patient safety more widely known so hospital wide
changes could occur in the way the patients were being treated. I could also consider offering
this information to doctors that I have built open lines of communication with.
Modifying the treatment regimen for patients with IDDM would require health care
professionals to be open to change. According to Standard 8, “the registered nurse attains
knowledge and competence that reflects current nursing practice” (ANA, 2010, p. 11). Nurses
would require education about the change in the standard of care for patients with IDDM. The
research articles listed above (Schroeder et al., 2012; Umpierrez, 2011; Shaw, 2009; Patel et al.,
SLIDING SCALE INSULIN AS A METHOD OF GLYCEMIC CONTROL
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2009) mentioned the importance of nursing education when delivering basal-bolus insulin
coverage. The pharmacy would need to be included in this change in patient care. The
pharmacy would need to order the insulin required by the doctor’s order for basal-bolus insulin
coverage for patients who require insulin for glycemic control. Changing from SSI to basalbolus insulin would probably require a committee with doctors, nurses, pharmacists, and staff
from patient quality and safety.
Conclusion
In conclusion, research shows that sliding scale insulin coverage of non-critically ill adult
patients who have been hospitalized is not based on research. A basal-bolus insulin regimen has
been found to be more effective in controlling the blood sugars of a non-critically ill adult
hospitalized patient. It is important for nurses to search for evidence to support their nursing
practice. It is the responsibility of the professional nurse to share research findings with other
nurses so that patients receive excellent evidence based nursing care.
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References
American Nurses Association [ANA] (2010). Nursing: Scope and standards of practice (2nd ed.).
Silver Springs, MD: Author
Fine-Overholt, E., Melnyk, B.M., Stillwell, S. B., & Williamson, K.M. (2010). Evidence-based
practice step by step: Critical appraisal of the evidence: part I. The American journal of
nursing, 110(7), 47-52. Doi:10.1097/01.NAJ.0000383935.22721.9c
Nieswiadomy, R. M. (2012). Foundations of nursing research (6th ed.). Boston: Pearson.
Patel, G. W., Roderman, N., Lee, K. A., Charles, M. M., Nguyen, D., Beougher, P., & ...
Casteneda, E. (2009). Sliding scale versus tight glycemic control in the noncritically ill at
a community hospital. Annals Of Pharmacotherapy, 43(11), 1774-1780.
doi:10.1345/aph.1M331
Schroeder, J. E., Liebergall, M., Raz, I., Egleston, R., Ben Sussan, G., Peyser, A. & Eldor, R.
(2012), Benefits of a simple glycaemic protocol in an orthopaedic surgery ward: a
randomized prospective study. Diabetes Metab. Res. Rev., 28: 71–75.
doi: 10.1002/dmrr.1217
Shaw K. (2009). The use of scheduled basal subcutaneous insulin in adult surgical patients: a
systematic review of current research. Southern Online Journal of Nursing Research
[serial online]. May 2009;9(3)Available from: CINAHL, Ipswich, MA. Accessed July 31,
2013.
Umpierrez, G., Smiley, D., Jacobs, S., Peng, L., Temponi, A., Mulligan, P., & ... Rizzo, M.
(2011). Randomized study of basal-bolus insulin therapy in the inpatient management of
patients with type 2 diabetes undergoing general surgery (RABBIT 2 Surgery). Diabetes
Care, 34(2), 256-261. doi:10.2337/dc10-1407