When to Notify Provider Before Starting Basal Insulin
The nurse should notify the provider immediately if the patient's blood glucose is ≥400 mg/dL (22.2 mmol/L), or if blood glucose is ≥300 mg/dL (16.7 mmol/L) with symptoms of hyperglycemia, before initiating basal insulin. Additionally, notify for blood glucose ≥300 mg/dL (16.7 mmol/L) with signs of ketosis (ketonuria ≥1+ or ketonaemia >0.5 mmol/L), as these patients may require IV insulin infusion instead of subcutaneous basal insulin 1.
Critical Thresholds Requiring Provider Notification
Immediate Notification Required:
Blood glucose ≥400 mg/dL (≥22.2 mmol/L): These patients typically need higher initial insulin doses (0.5 U/kg/day total daily dose) and may require more aggressive management 2
Blood glucose ≥300 mg/dL (16.7 mmol/L) with symptomatic hyperglycemia: Symptoms include polyuria, polydipsia, weight loss, or altered mental status. These patients may need immediate insulin therapy with consideration for IV insulin if severely symptomatic 3, 4
Pre-prandial blood glucose ≥300 mg/dL (16.5 mmol/L) with ketosis present: Check for ketonuria (≥1+) or ketonaemia (>0.5 mmol/L). If ketonaemia is ≥1.5 mmol/L or ketonuria is 2+, the patient requires transfer to ICU for IV insulin infusion therapy rather than subcutaneous basal insulin 1
Standard Protocol for Initiating Basal Insulin
For patients WITHOUT the above critical thresholds, nurses can typically proceed with basal insulin initiation following established protocols, but should still notify the provider for documentation and order verification:
Blood glucose 201-400 mg/dL (11.2-22.2 mmol/L): Start with 0.5 U/kg/day total daily dose (50% basal, 50% nutritional) 2
Blood glucose 140-200 mg/dL (7.8-11.1 mmol/L): Start with 0.4 U/kg/day total daily dose 2
Elderly (≥70 years) or renal impairment (GFR <60 mL/min): Start with lower dose of 0.2-0.3 U/kg/day regardless of blood glucose level 2
Additional Situations Requiring Provider Notification
Persistent Hyperglycemia on Correctional Insulin Alone:
Notify the provider if ≥2 point-of-care blood glucose measurements are ≥180 mg/dL (≥10.0 mmol/L) within a 24-hour period in patients currently on correctional insulin only. These patients need scheduled basal insulin added to their regimen 5.
Confirmed Admission Blood Glucose:
For patients with diabetes treated with diet or noninsulin medications prior to admission, notify the provider if admission blood glucose is ≥180 mg/dL (≥10.0 mmol/L) to initiate scheduled insulin therapy rather than correctional insulin alone 5.
Common Pitfalls to Avoid
Do not delay notification for blood glucose ≥400 mg/dL thinking you can manage with sliding scale insulin alone. Sliding scale insulin as sole therapy is strongly discouraged and leads to poor glycemic control 2, 6
Do not start basal insulin without checking for ketosis when blood glucose is ≥300 mg/dL. Missing ketosis can lead to inappropriate subcutaneous insulin administration when IV insulin is needed 1
Do not use the same starting dose for elderly patients or those with renal impairment. These patients require 30-50% lower starting doses to prevent hypoglycemia 2
For patients with type 1 diabetes, never hold basal insulin even if NPO. These patients require continuous basal insulin coverage and provider notification is essential if there's any question about insulin administration 6