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Diabetes Care Volume 39, Supplement 1, January 2016 S99

13. Diabetes Care in the Hospital American Diabetes Association

Diabetes Care 2016;39(Suppl. 1):S99S104 | DOI: 10.2337/dc16-S016

Recommendations
c Consider performing an A1C on all patients with diabetes or hyperglycemia
admitted to the hospital if not performed in the prior 3 months. C
c Insulin therapy should be initiated for treatment of persistent hyperglycemia
starting at a threshold $180 mg/dL (10.0 mmol/L). Once insulin therapy is
started, a target glucose range of 140180 mg/dL (7.810.0 mmol/L) is recom-
mended for the majority of critically ill patients A and noncritically ill patients. C
c More stringent goals, such as 110140 mg/dL (6.17.8 mmol/L) may be ap-
propriate for selected critically ill patients, as long as this can be achieved
without signicant hypoglycemia. C

13. DIABETES CARE IN THE HOSPITAL


c Intravenous insulin infusions should be administered using validated written or
computerized protocols that allow for predened adjustments in the insulin
infusion rate based on glycemic uctuations and insulin dose. E
c A basal plus bolus correction insulin regimen is the preferred treatment for
noncritically ill patients with poor oral intake or those who are taking nothing
by mouth. An insulin regimen with basal, nutritional, and correction compo-
nents is the preferred treatment for patients with good nutritional intake. A
c The sole use of sliding scale insulin in the inpatient hospital setting is strongly
discouraged. A
c A hypoglycemia management protocol should be adopted and implemented
by each hospital or hospital system. A plan for preventing and treating hypo-
glycemia should be established for each patient. Episodes of hypoglycemia in
the hospital should be documented in the medical record and tracked. E
c The treatment regimen should be reviewed and changed if necessary to prevent
further hypoglycemia when a blood glucose value is ,70 mg/dL (3.9 mmol/L). C
c There should be a structured discharge plan tailored to the individual patient. B

Both hyperglycemia and hypoglycemia are associated with adverse outcomes, in-
cluding death (1,2). Therefore, hospital goals for the patient with diabetes include
preventing both hyperglycemia and hypoglycemia, promoting the shortest safe
hospital stay, and providing an effective transition out of the hospital that prevents
complications and readmission.
High-quality hospital care requires both hospital care delivery standards, often
assured by structured order sets, and quality assurance standards for process
improvement.

HOSPITAL CARE DELIVERY STANDARDS


Best practice protocols, reviews, and guidelines (2) are inconsistently imple-
mented within hospitals. To correct this, hospitals have established protocols for
structured patient care and structured order sets, which include computerized
physician order entry (CPOE).

Computerized Physician Order Entry


In 2009, the federal Health Information Technology for Economic and Clinical Health
(HITECH) Act was enacted. A core requirement for stage 1 of the HITECH Acts Suggested citation: American Diabetes Associa-
meaningful use included CPOE. The Institute of Medicine also recommends tion. Diabetes care in the hospital. Sec. 13. In
Standards of Medical Care in Diabetesd2016.
CPOE to prevent medication-related errors and increase efciency in medication
Diabetes Care 2016;39(Suppl. 1):S99S104
administration (3). A Cochrane review of randomized controlled trials using com-
2016 by the American Diabetes Association.
puterized advice to improve glucose control in the hospital found signicant im- Readers may use this article as long as the work
provement in percentage of time in target glucose range, lower mean blood glucose, is properly cited, the use is educational and not
and no increase in hypoglycemia (4). As hospitals move to comply with meaningful for prot, and the work is not altered.
S100 Diabetes Care in the Hospital Diabetes Care Volume 39, Supplement 1, January 2016

use, efforts should be made to ensure insulin therapy is initiated, a glucose target for glycemic uctuations and insulin dose
that all components of structured insu- of 140180 mg/dL (7.810.0 mmol/L) is rec- (2,12).
lin order sets are incorporated in the ommended for most critically ill patients
Noncritical Care Setting
orders (5). Thus, where feasible, there (2). More stringent goals, such as 110140
Outside of critical care units, scheduled
should be routine structured order sets mg/dL (6.17.8 mmol/L) may be appropri- subcutaneous insulin injections should
that produce computerized advice for ate for select patients, such as cardiac sur- align with meals and bedtime or every
glucose control. gery patients (7), and patients with acute 46 h if no meals or if continuous enteral/
ischemic cardiac (9) or neurological events parenteral therapy is used (2). A basal
CONSIDERATIONS ON ADMISSION provided the targets can be achieved plus correction insulin regimen is the
Initial orders should state that the pa- without signicant hypoglycemia. preferred treatment for patients with
tient has type 1 diabetes or type 2 diabe- A glucose target between 140 and 180 poor oral intake or those who are taking
tes or no previous history of diabetes. If mg/dL (between 7.8 and 10.0 mmol/L) is nothing by mouth (NPO) (13). An insulin
the patient has diabetes, an order for an recommended for most patients in non- regimen with basal, nutritional, and
A1C should be placed if none is available critical care units (2). Patients with a prior correction components (basalbolus) is
within the prior 3 months (2). In addition, history of successful tight glycemic con- the preferred treatment for patients
diabetes self-management education trol in the outpatient setting who are clin- with good nutritional intake (10). In
should be ordered and should include ically stable may be maintained with a such instances, point-of-care (POC) glu-
appropriate skills needed after dis- glucose target below 140 mg/dL cose testing should be performed imme-
charge, such as taking glycemic medica- (7.8 mmol/L). Conversely, higher glucose diately before meals.
tion, glucose monitoring, and coping with ranges may be acceptable in terminally ill If oral intake is poor, a safer procedure
hypoglycemia (2). patients, in patients with severe comor- is to administer the short-acting insulin
bidities, and in in-patient care settings after the patient eats or to count the car-
GLYCEMIC TARGETS IN where frequent glucose monitoring or bohydrates and cover the amount in-
HOSPITALIZED PATIENTS close nursing supervision is not feasible. gested. A randomized controlled trial
Standard Denition of Glucose Clinical judgment combined with ongo- has shown that basalbolus treatment
Abnormalities ing assessment of the patients clinical improved glycemic control and reduced
Hyperglycemia in hospitalized patients status, including changes in the trajectory hospital complications compared with
has been dened as blood glucose of glucose measures, illness severity, nu- sliding scale insulin in general surgery
.140 mg/dL (7.8 mmol/L). Blood glu- tritional status, or concomitant medica- patients with type 2 diabetes (14).
cose levels that are signicantly and tions that might affect glucose levels
Type 1 Diabetes
persistently above this level require re- (e.g., glucocorticoids), should be incorpo-
For patients with type 1 diabetes, dosing
assessing treatment. An admission A1C rated into the day-to-day decisions re-
insulin based solely on premeal glucose
value $6.5% (48 mmol/mol) suggests garding insulin doses (2).
levels does not account for basal insulin
that diabetes preceded hospitalization
requirements or calorie intake, increas-
(see Section 2 Classication and Diag- ANTIHYPERGLYCEMIC AGENTS IN ing both hypoglycemia and hyperglyce-
nosis of Diabetes). Hypoglycemia in HOSPITALIZED PATIENTS mia risks and potentially leading to
hospitalized patients has been dened
In most instances in the hospital setting, diabetic ketoacidosis (DKA). Typically
as blood glucose ,70 mg/dL (3.9 mmol/L)
insulin is the preferred treatment for basal insulin dosing schemes are based
and severe hypoglycemia as ,40 mg/dL
glycemic control (2). However, in certain on body weight, with some evidence
(2.2 mmol/L) (6).
circumstances, it may be appropriate to that patients with renal insufciency
Moderate Versus Tight Glycemic continue home regimens including oral should be treated with lower doses (15).
Control antihyperglycemic medications (10). If Transitioning Intravenous to
Glycemic goals within the hospital set- oral medications are held in the hospi- Subcutaneous Insulin
ting have changed in the last 14 years. tal, there should be a protocol for re- When discontinuing intravenous insulin, a
The initial target of 80110 mg/dL (4.4 suming them 12 days before discharge. transition protocol is associated with
6.1 mmol/L) was based on a 42% relative less morbidity and lower costs of care
reduction in intensive care unit mortal- Insulin Therapy
(16) and is therefore recommended. A
ity in critically ill surgical patients (7). The sole use of sliding scale insulin in the
patient with type 1 or type 2 diabetes
However, a meta-analysis of over 26 stud- inpatient hospital setting is strongly dis-
being transitioned to outpatient subcu-
ies, including the largest, Normoglycemia couraged (2,11).
taneous insulin should receive sub-
in Intensive Care EvaluationSurvival Critical Care Setting cutaneous insulin 12 h before the
Using Glucose Algorithm Regulation In the critical care setting, continuous intravenous insulin is discontinued.
(NICE-SUGAR), showed increased rates intravenous insulin infusion has been Converting to basal insulin at 6080%
of severe hypoglycemia and mortality shown to be the best method for achiev- of the daily infusion dose has been
in tightly versus moderately controlled ing glycemic targets. Intravenous insulin shown to be effective (2,16,17).
cohorts (8). This evidence established infusions should be administered based
new standards: initiate insulin therapy on validated written or computerized Noninsulin Therapies
for persistent hyperglycemia greater protocols that allow for predened ad- The safety and efcacy of noninsulin
than 180 mg/dL (10.0 mmol/L). Once justments in the infusion rate, accounting antihyperglycemic therapies in the hospital
care.diabetesjournals.org Diabetes Care in the Hospital S101

setting is an area of active research. A re- 2. Preoperative risk assessment for pa- any correctable underlying cause of
cent randomized pilot trial in general tients at high risk for ischemic heart DKA, such as sepsis. Low-dose insulin,
medicine and surgery patients reported disease and those with autonomic given intravenously, intramuscularly, or
that a dipeptidyl peptidase 4 inhibitor neuropathy or renal failure. subcutaneously, is safe and effective in
alone or in combination with basal insulin 3. The morning of surgery or proce- treating DKA (23).
was well tolerated and resulted in similar dure, hold any oral hypoglycemic Several studies have shown that in
glucose control and frequency of hypogly- agents and give half of NPH dose or uncomplicated mild-to-moderate DKA,
cemia compared with a basalbolus regi- full doses of a long-acting analog or subcutaneous lispro (24) or aspart insu-
men (18). A report suggested that given pump basal insulin. lin (25) dosed every 12 h is as effective
the serious consequences of hypoglyce- 4. Monitor blood glucose every 46 h and safe as intravenous regular insulin
mia, incretin agents, which do not cause while NPO and dose with short- when used in conjunction with standard
hypoglycemia, may substitute for insulin, acting insulin as needed. intravenous uid and potassium replace-
sulfonylureas, or metformin (19). A re- ment protocols (23). If subcutaneous ad-
view of several studies concluded that in- A review found that tight peri- ministration is used, it is important, for
cretins show promise; however, proof of operative glycemic control did not im- safety reasons, to provide adequate nurs-
safety and efcacy compared with stan- prove outcomes and was associated ing training and care and frequent bed-
dard therapies await the results of further with more hypoglycemia (22); there- side testing. However, in critically ill and
randomized controlled trials (20). fore, in general, tighter glycemic targets mentally obtunded patients, continuous
than mentioned above are not advised. intravenous insulin infusion is required.
STANDARDS FOR SPECIAL Several studies have shown that the use
Moderate Versus Tight Glycemic of bicarbonate in patients with DKA made
SITUATIONS Control Targets no difference in resolution of acidosis or
Enteral/Parenteral Feedings In general surgery (noncardiac) patients, time to discharge, and its use is generally
For full enteral/parenteral feeding guid- basal insulin plus premeal regular or not recommended (26).
ance, the reader is encouraged to consult short-acting insulin (basalbolus) cover-
review articles (2,21) and see Table 13.1. age has been associated with improved Continuous Glucose Monitoring
glycemic control and lower rates of peri- Continuous glucose monitoring (CGM)
Glucocorticoid Therapy operative complications compared with provides continuous estimates, direction,
The duration of glucocorticoid action the traditional sliding scale regimen and magnitude of glucose trends, which
must be considered to prevent hyper- (regular or short-acting insulin coverage may have an advantage over POC glucose
glycemia. Once-a-day short-acting ste- only with no basal dosing) (13,14). testing in detecting and reducing the in-
roids such as prednisone peak in about cidence of hypoglycemia. Several studies
8 h, so coverage with intermediate- Diabetic Ketoacidosis and have shown that CGM use did not im-
acting insulin (NPH) may be sufcient. For Hyperosmolar Hyperglycemic State prove glucose control, but detected a
long-acting steroids such as dexametha- There is considerable variability in the greater number of hypoglycemic events
sone or multidose or continuous steroid presentation of DKA and hyperosmolar than POC testing. A recent review has rec-
use, long-acting insulin may be used hyperglycemic state, ranging from eu- ommended against using CGM in adults
(10,21). Whatever orders are started, glycemia or mild hyperglycemia and in a hospital setting until more safety and
adjustments based on POC glucose test acidosis to severe hyperglycemia, efcacy data become available (27).
results are critical. dehydration, and coma; therefore,
treatment individualization based on a TREATING AND PREVENTING
Perioperative Care careful clinical and laboratory assess- HYPOGLYCEMIA
Standards for perioperative care include ment is needed (23). Patients with or without diabetes may
the following: Management goals include restora- experience hypoglycemia in the hospital
tion of circulatory volume and tissue setting. While increased mortality is as-
1. Target glucose range for the peri- perfusion, resolution of hyperglycemia, sociated with hypoglycemia, it may be a
operative period should be 80180 and correction of electrolyte imbalance marker of underlying disease rather
mg/dL (4.410.0 mmol/L). and ketosis. It is also important to treat than the cause of increased mortality.
However, until it is proven not to be
Table 13.1Insulin dosing for enteral/parenteral feedings causal, it is prudent to avoid hypoglyce-
Situation Basal Bolus mia. Despite the preventable nature of
Continuous enteral feedings Glargine q.d. or SQ rapid-acting correction many inpatient episodes of hypoglyce-
NPH/detemir b.i.d. every 4 h mia, institutions are more likely to have
Bolus enteral feedings Continue prior basal; SQ rapid-acting insulin with nursing protocols for hypoglycemia
if none, consider each bolus feeding to cover treatment than for its prevention when
10 units NPH or the bolus feeding and to both are needed.
glargine insulin correct for hyperglycemia
Parenteral feedings Regular insulin to Rapid-acting insulin SQ every Triggering Events
TPN IV bottle 4 h to correct for hyperglycemia Iatrogenic hypoglycemia triggers may in-
clude sudden reduction of corticosteroid
IV, intravenous; SQ, subcutaneous; TPN, total parenteral nutrition.
dose, altered ability of the patient to
S102 Diabetes Care in the Hospital Diabetes Care Volume 39, Supplement 1, January 2016

report symptoms, reduced oral intake, hypoglycemia protocol be adopted and Orders should also reect that the meal
emesis, new NPO status, inappropriate implemented in each hospital system, delivery and nutritional insulin coverage
timing of short-acting insulin in relation and all episodes should be tracked in be matched, as their variability often
to meals, reduced infusion rate of intrave- the medical records (2). creates the possibility of hyperglycemic
nous dextrose, and unexpected interrup- and hypoglycemic events.
tion of oral, enteral, or parenteral feedings. SELF-MANAGEMENT IN THE
HOSPITAL
Predictors of Hypoglycemia TRANSITION FROM THE ACUTE
Diabetes self-management in the hos- CARE SETTING
In one study, 84% of patients with an
pital may be appropriate for select
episode of severe hypoglycemia (,40 A Cochrane systematic review noted
youth and adult patients. Candidates
mg/dL [2.2 mmol/L]) had a prior episode that a structured discharge plan tailored
include patients who successfully con-
of hypoglycemia (,70 mg/dL [3.9 to the individual patient may reduce
duct self-management of diabetes at
mmol/L]) during the same admission length of hospital stay, readmission rates,
home, have the cognitive and physical
(28). In another study of hypoglycemic and increase patient satisfaction (33).
skills needed to successfully self-
episodes (,50 mg/dL [2.8 mmol/L]), Therefore, there should be a structured
administer insulin, and perform self-
78% of patients were using basal insulin, discharge plan tailored to each patient.
monitoring of blood glucose. In addition,
with the incidence of hypoglycemia peak- Discharge planning should begin at ad-
they should have adequate oral intake,
ing between midnight and 6 A.M. Despite mission and be updated as patient needs
be procient in carbohydrate estima-
recognition of hypoglycemia, 75% of pa- change.
tion, use multiple daily insulin injec-
tients did not have their dose of basal in- Transition from the acute care setting
tions or continuous subcutaneous
sulin changed before the next insulin is a risky time for all patients. Inpatients
insulin infusion (CSII) pump therapy,
administration (29). may be discharged to varied settings,
have stable insulin requirements, and
including home (with or without visiting
Hypoglycemia Treatment understand sick-day management. If
nurse services), assisted living, rehabili-
There should be a standardized hospital- self-management is to be used, a pro-
tocol should include a requirement tation, or skilled nursing facilities. For
wide, nurse-initiated hypoglycemia the patient who is discharged to assisted
treatment protocol to immediately ad- that the patient, nursing staff, and phy-
sician agree that patient self-management living or to home, the optimal program
dress hypoglycemia (,70 mg/dL [3.9 will need to consider diabetes type and
mmol/L]) (2). is appropriate. If CSII is to be used, hospital
policy and procedures delineating guide- severity, effects of the patients illness
lines for CSII therapy are advised (31). on blood glucose levels, and the patients
Prevention
Common preventable sources of iatro- capacities and desires.
genic hypoglycemia are improper pre- MEDICAL NUTRITION THERAPY IN An outpatient follow-up visit with
scribing of hypoglycemic medications, THE HOSPITAL the primary care provider, endocrinol-
inappropriate management of the rst The goals of medical nutrition therapy are ogist, or diabetes educator within 1
episode of hypoglycemia, and nutrition to optimize glycemic control, provide month of discharge is advised for all
insulin mismatch, often related to an adequate calories to meet metabolic patients having hyperglycemia in the
unexpected interruption of nutrition. A demands, address personal food pre- hospital. If glycemic medications are
study of bundled preventative thera- ferences, and create a discharge plan. changed or glucose control is not opti-
pies including proactive surveillance of The ADA does not endorse any single mal at discharge, continuing contact
glycemic outliers and an interdisciplinary meal plan or specied percentages of may be needed to avoid hyperglycemia
data-driven approach to glycemic man- macronutrients, and the term ADA and hypoglycemia. A recent discharge
agement showed that hypoglycemic diet should no longer be used. Current algorithm for glycemic medication ad-
episodes in the hospital could be pre- nutrition recommendations advise indi- justment based on admission A1C
vented. Compared with baseline, the vidualization based on treatment goals, found that the average A1C in patients
study found that the relative risk of a se- physiological parameters, and medication with diabetes decreased from 8.7% (72
vere hypoglycemic event was 0.44 (95% use. Consistent carbohydrate meal plans mmol/mol) on admission to 7.3% (56
CI 0.340.58) in the postintervention pe- are preferred by many hospitals as they mmol/mol) 3 months after discharge
riod (30). facilitate matching the prandial insulin (34). Therefore, if an A1C from the prior
dose to the amount of carbohydrate con- 3 months is unavailable, measuring the
Hospital Hypoglycemia Prevention sumed (32). A1C in all patients with diabetes or hy-
and Treatment When the nutritional issues in the perglycemia admitted to the hospital is
The Joint Commission recommends that hospital are complex, a registered dieti- recommended.
all hypoglycemic episodes be evaluated tian, knowledgeable and skilled in med- Clear communication with outpatient
for a root cause and the episodes be ical nutrition therapy, can serve as an providers either directly or via hospital
aggregated and reviewed to address individual inpatient team member. discharge summaries facilitates safe
systemic issues. An American Diabetes That person should be responsible for transitions to outpatient care. Providing
Association (ADA) hypoglycemia con- integrating information about the pa- information regarding the cause of hy-
sensus report suggested that the treat- tients clinical condition, meal planning, perglycemia (or the plan for determin-
ment regimen be reviewed when a blood and lifestyle habits and for establishing ing the cause), related complications
glucose value is ,70 mg/dL (3.9 mmol/L), a realistic treatment goals after discharge. and comorbidities, and recommended
care.diabetesjournals.org Diabetes Care in the Hospital S103

treatments can assist outpatient pro- with appropriate education at the time status should be conrmed through con-
viders as they assume ongoing care. of discharge in order to avoid a poten- ventional laboratory glucose tests. The
The Agency for Healthcare Research tially dangerous hiatus in care. FDA established a separate category for
and Quality (AHRQ) recommends that POC glucose meters for use in health care
at a minimum, discharge plans include Quality Assurance Standards
settings and has released a draft on in-
the following (35): Even the best orders may not be carried
hospital use with stricter standards. Before
out in a way that improves quality, nor are
choosing a device, consider the devices
they automatically updated when new
Medication Reconciliation approval status and accuracy.
evidence arises. To this end, the Joint
The patients medications must be Commission has an accreditation program
cross-checked to ensure that no References
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Structured Discharge Communication outcomes, but the studies are few. A sensus statement on inpatient glycemic
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S104 Diabetes Care in the Hospital Diabetes Care Volume 39, Supplement 1, January 2016

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