Why Won't the Sliding Scale Go Away?

Basal-bolus-supplement insulin is the standard way patients on a multiple daily injection (MDI) insulin program take insulin at home. However, in many hospitals, this physiological approach to insulin delivery is supplanted by sliding-scale insulin, wherein fast-or rapid-acting insulin only is given subcutaneously and only in response to particularly high blood glucose levels. Evidence has mounted that sliding-scale insulin leads to an increase in blood glucose and an increase in serious hospital morbidity compared to basal-bolus-supplement. To highlight this evidence, the Vancouver Island Health Authority has tried an educational approach, combined with changes to clinical order sets, in an effort to replace sliding-scale insulin with basal-bolus-supplement. Initial results have been disappointing, and on-going efforts are required to understand why the sliding scale appears so deeply entrenched.