Why Diabetic Patients Need a “Sick Day” Plan

In October 2010, a 33-year-old woman with type 1 diabetes presented to a medical center in Cook County, Illinois, with shortness of breath. She was diagnosed with excessive fluid around her lungs, for which she received treatment. When her pain persisted, she was placed on hydromorphone. A long-­acting form of insulin was also  prescribed.

Two days later, the woman experienced respiratory arrest­—presumed to be a reaction to the medication. She was resuscitated and remained in the ICU. Although she was not eating food by mouth, no order for a diet change was received or documented. She continued to be administered insulin and went into a diabetic coma, dying about a week after admission.

The plaintiff claimed that the internal medicine physician employed by the hospital failed to review the decedent’s medical chart and discuss the decedent’s risk for low blood sugar levels with the attending physician. The defendants argued that the decedent was receiving regular dialysis due to end-stage renal failure and had a short life expectancy.

What was the outcome? >>

OUTCOME 
A $2 million settlement was reached.

COMMENT 
This patient’s admission to the ICU and continued monitoring were obviously stressful and ensured that her serum glucose would be high. Systems should have been in place to prevent a fatal outcome—yet the system failed in this case.

The clinicians failed to recognize the need for closer monitoring and management in a sick, acutely stressed patient. The internist did not revisit the prescribed diet and did not appreciate the impact an acute illness can have on glycemic control—and thus did not order closer serum glucose monitoring.

Because diabetes is common, jurors expect competent management; as a result, this case was likely difficult to defend. The case report tells us that the defense did not challenge a breach of the standard of care (liability) but instead focused on the ultimate impact of the mistake, given the patient’s end-stage renal failure and short life expectancy (damages).

The $2 million settlement is relatively restrained, given the patient’s young age and the location of the case. This suggests the defense had some success arguing that the patient, at baseline, was gravely ill with a diminished lifespan.

As clinicians, we would all agree that an acutely stressed, hospitalized diabetic patient should be managed closely. But how often do we see diabetic patients in an ambulatory setting who are moderately stressed, ill, vomiting, and not eating? How often do we consider the possibility that these patients could slip out of control if not monitored more closely?

While we can’t revamp our diabetic patients’ regimens for every cold, we can encourage them to develop a “sick day” plan and remind them to be vigilant about managing their diabetes during illness. Consider the “sick day” advice given to patients by the Joslin Diabetes Center:
• Always take your diabetes medication. If you have difficulty keeping the medicine down due to vomiting, call your clinician.
• Check your blood glucose level at least 4 times a day. If you are too sick to test it yourself, have someone else do it. Record your levels in case you need to contact your clinician.
• Check for ketones if your blood glucose is 250 or higher. Again, write down your levels for reference.
• Stick to your normal meal plan, if possible.
• Drink lots of sugar-free liquids to prevent dehydration.¹

Patients are also advised to contact their health care provider if they have any of the following symptoms: a fever of more than 100.5°F; vomiting or diarrhea of more than two hours’ duration; blood glucose levels higher than 250 mg after two checks, or levels that do not decrease after extra insulin is taken; and moderate or large ketones.¹

The instruction to call the office for any fever higher than 100.5°F may seem abundantly cautious. But the discussion that ensues would serve as an opportunity to reinforce the need for closer monitoring—perhaps preventing a patient with a modest illness from spiraling out of glycemic control. —DML

REFERENCE 
1. Joslin Diabetes Center. Sick Days. www.joslin.org/info/Sick_Days.html. Accessed June 10, 2015.

In October 2010, a 33-year-old woman with type 1 diabetes presented to a medical center in Cook County, Illinois, with shortness of breath. She was diagnosed with excessive fluid around her lungs, for which she received treatment. When her pain persisted, she was placed on hydromorphone. A long-­acting form of insulin was also  prescribed.

Two days later, the woman experienced respiratory arrest­—presumed to be a reaction to the medication. She was resuscitated and remained in the ICU. Although she was not eating food by mouth, no order for a diet change was received or documented. She continued to be administered insulin and went into a diabetic coma, dying about a week after admission.

The plaintiff claimed that the internal medicine physician employed by the hospital failed to review the decedent’s medical chart and discuss the decedent’s risk for low blood sugar levels with the attending physician. The defendants argued that the decedent was receiving regular dialysis due to end-stage renal failure and had a short life expectancy.

What was the outcome? >>

OUTCOME 
A $2 million settlement was reached.

COMMENT 
This patient’s admission to the ICU and continued monitoring were obviously stressful and ensured that her serum glucose would be high. Systems should have been in place to prevent a fatal outcome—yet the system failed in this case.

The clinicians failed to recognize the need for closer monitoring and management in a sick, acutely stressed patient. The internist did not revisit the prescribed diet and did not appreciate the impact an acute illness can have on glycemic control—and thus did not order closer serum glucose monitoring.

Because diabetes is common, jurors expect competent management; as a result, this case was likely difficult to defend. The case report tells us that the defense did not challenge a breach of the standard of care (liability) but instead focused on the ultimate impact of the mistake, given the patient’s end-stage renal failure and short life expectancy (damages).

The $2 million settlement is relatively restrained, given the patient’s young age and the location of the case. This suggests the defense had some success arguing that the patient, at baseline, was gravely ill with a diminished lifespan.

As clinicians, we would all agree that an acutely stressed, hospitalized diabetic patient should be managed closely. But how often do we see diabetic patients in an ambulatory setting who are moderately stressed, ill, vomiting, and not eating? How often do we consider the possibility that these patients could slip out of control if not monitored more closely?

While we can’t revamp our diabetic patients’ regimens for every cold, we can encourage them to develop a “sick day” plan and remind them to be vigilant about managing their diabetes during illness. Consider the “sick day” advice given to patients by the Joslin Diabetes Center:
• Always take your diabetes medication. If you have difficulty keeping the medicine down due to vomiting, call your clinician.
• Check your blood glucose level at least 4 times a day. If you are too sick to test it yourself, have someone else do it. Record your levels in case you need to contact your clinician.
• Check for ketones if your blood glucose is 250 or higher. Again, write down your levels for reference.
• Stick to your normal meal plan, if possible.
• Drink lots of sugar-free liquids to prevent dehydration.¹

Patients are also advised to contact their health care provider if they have any of the following symptoms: a fever of more than 100.5°F; vomiting or diarrhea of more than two hours’ duration; blood glucose levels higher than 250 mg after two checks, or levels that do not decrease after extra insulin is taken; and moderate or large ketones.¹

The instruction to call the office for any fever higher than 100.5°F may seem abundantly cautious. But the discussion that ensues would serve as an opportunity to reinforce the need for closer monitoring—perhaps preventing a patient with a modest illness from spiraling out of glycemic control. —DML

REFERENCE 
1. Joslin Diabetes Center. Sick Days. www.joslin.org/info/Sick_Days.html. Accessed June 10, 2015.

In October 2010, a 33-year-old woman with type 1 diabetes presented to a medical center in Cook County, Illinois, with shortness of breath. She was diagnosed with excessive fluid around her lungs, for which she received treatment. When her pain persisted, she was placed on hydromorphone. A long-­acting form of insulin was also  prescribed.

Two days later, the woman experienced respiratory arrest­—presumed to be a reaction to the medication. She was resuscitated and remained in the ICU. Although she was not eating food by mouth, no order for a diet change was received or documented. She continued to be administered insulin and went into a diabetic coma, dying about a week after admission.

The plaintiff claimed that the internal medicine physician employed by the hospital failed to review the decedent’s medical chart and discuss the decedent’s risk for low blood sugar levels with the attending physician. The defendants argued that the decedent was receiving regular dialysis due to end-stage renal failure and had a short life expectancy.

What was the outcome? >>

OUTCOME 
A $2 million settlement was reached.

COMMENT 
This patient’s admission to the ICU and continued monitoring were obviously stressful and ensured that her serum glucose would be high. Systems should have been in place to prevent a fatal outcome—yet the system failed in this case.

The clinicians failed to recognize the need for closer monitoring and management in a sick, acutely stressed patient. The internist did not revisit the prescribed diet and did not appreciate the impact an acute illness can have on glycemic control—and thus did not order closer serum glucose monitoring.

Because diabetes is common, jurors expect competent management; as a result, this case was likely difficult to defend. The case report tells us that the defense did not challenge a breach of the standard of care (liability) but instead focused on the ultimate impact of the mistake, given the patient’s end-stage renal failure and short life expectancy (damages).

The $2 million settlement is relatively restrained, given the patient’s young age and the location of the case. This suggests the defense had some success arguing that the patient, at baseline, was gravely ill with a diminished lifespan.

As clinicians, we would all agree that an acutely stressed, hospitalized diabetic patient should be managed closely. But how often do we see diabetic patients in an ambulatory setting who are moderately stressed, ill, vomiting, and not eating? How often do we consider the possibility that these patients could slip out of control if not monitored more closely?

While we can’t revamp our diabetic patients’ regimens for every cold, we can encourage them to develop a “sick day” plan and remind them to be vigilant about managing their diabetes during illness. Consider the “sick day” advice given to patients by the Joslin Diabetes Center:
• Always take your diabetes medication. If you have difficulty keeping the medicine down due to vomiting, call your clinician.
• Check your blood glucose level at least 4 times a day. If you are too sick to test it yourself, have someone else do it. Record your levels in case you need to contact your clinician.
• Check for ketones if your blood glucose is 250 or higher. Again, write down your levels for reference.
• Stick to your normal meal plan, if possible.
• Drink lots of sugar-free liquids to prevent dehydration.¹

Patients are also advised to contact their health care provider if they have any of the following symptoms: a fever of more than 100.5°F; vomiting or diarrhea of more than two hours’ duration; blood glucose levels higher than 250 mg after two checks, or levels that do not decrease after extra insulin is taken; and moderate or large ketones.¹

The instruction to call the office for any fever higher than 100.5°F may seem abundantly cautious. But the discussion that ensues would serve as an opportunity to reinforce the need for closer monitoring—perhaps preventing a patient with a modest illness from spiraling out of glycemic control. —DML

REFERENCE 
1. Joslin Diabetes Center. Sick Days. www.joslin.org/info/Sick_Days.html. Accessed June 10, 2015.