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Diabetes Mellitus and Hyperglycemia

Management in the Hospitalized Patient
Patricia A. Mackey, FNP-BC, BC-ADM, and Michael D. Whitaker, MD, FRCPC

ABSTRACT
Diabetes mellitus and hyperglycemia are common in hospitalized patients.
Uncontrolled hyperglycemia during hospitalization is associated with poor outcomes.
A glucose goal of 140-180 mg/dL is recommended. Scheduled subcutaneous insulin
with basal, prandial, and correction components is preferred for treating diabetes in
nonecritically ill patients. The pharmacodynamics of insulins differ, and the type of
insulin used should match daily glucose excursions. Varying hospital settings may
warrant using a particular insulin type to achieve optimal glucose control. Herein we
describe approaches to address hyperglycemia in the hospitalized patient on the basis of
insulin pharmacodynamic profiles.

Keywords: basal-bolus insulin, correction insulin, diabetes mellitus, hospitalized
patient, hyperglycemia
Ó 2015 Elsevier, Inc. All rights reserved.

O
ptimal glucose control is a challenge for agents (glucocorticoids, octreotide, catecholamines,
hospitalized patients. Proper treatment of and calcineurin inhibitors); the administration of
hyperglycemia while avoiding hypoglyce- contrast agents with certain tests; enteral and total
mia should be the goal of multidisciplinary teams parenteral nutrition (TPN); and the stress induced by
(endocrinologists, hospitalists, nurses, surgeons, the hospitalization itself.
advanced-level practitioners, pharmacists, and inten-
sivists) working together to provide care for the pa- GLYCEMIC GOALS
tient with diabetes mellitus or hyperglycemia in the Although several organizations have issued guide-
hospital setting. Hyperglycemia in hospitalized pa- lines for outpatient glucose management, no
tients can represent previously known diabetes, un- guidelines or protocols have been formulated for
diagnosed diabetes, or illness-related hyperglycemia. inpatient management. Maintaining glucose levels
Hemoglobin A1c values  6.5% suggest that diabetes between 140 and 180 mg/dL is recommended for
preceded the hospitalization.1 Numerous studies have the majority of hospitalized patients.1 Individualized
indicated that targeted glucose control in the hospital goals for younger patients without comorbidities
has been shown to improve clinical outcomes; the (with previous stable glucose control before
association between hyperglycemia in hospitalized admission), or for the elderly, terminally ill, or those
patients (with or without diabetes) and the increased with extensive comorbidities (eg, congestive heart
risk for morbidity and mortality have been well failure, cirrhosis, and renal failure), have been
established.2 established for use in the outpatient setting, but no
Challenges encountered in the hospital setting recommendations exist for inpatient glycemic goals
can make controlling glucose difficult. These chal- for these different groups.
lenges include a new diagnosis of diabetes; infection; Standardized glycemic goals for certain pop-
a more rigid diet; inactivity; decreased appetite; ulations of hospitalized patients have suggested that
variable renal and hepatic status; an unpredictable targets < 110 mg/dL are not recommended and may
schedule of testing, procedures, and surgical in- lead to poor outcomes, especially in critically ill
terventions; the use of hyperglycemic-provoking patients.1 Recent studies failed to show a significant

www.npjournal.org The Journal for Nurse Practitioners - JNP 531

hypoglycemia (blood glucose < 70 nents is the preferred treatment method for the mg/dL). should not be used in patients who have neutral protamine Hagedorn insulin (NPH). and potential For optimal glucose control. relationship and trying to mimic a natural. Using rapid-acting insulin at Oral Agents mealtimes and a long-acting basal insulin (programs Oral antidiabetic agents used in the hospital are with multiple daily injections) best mimics the natural difficult to titrate. caloric and protein losses.4 during the hospital stay. and then nor- prolonged nothing-by-mouth (NPO) status. have not been studied for safety physiologic responses of the body (Figure. Issue 5.3. that involve IV contrast with type 1 diabetes mellitus or post-pancreatectomy dye.JNP Volume 11. but severe hypoglycemia (blood glucose paucity of accepted insulin algorithms to facilitate < 40 mg/dL) could provoke neurologic effects or inpatient glucose management. delay in patients with a history of good glycemic control wound healing. prandial. Metformin. particularly in elderly patients and pa. the to the underlying illness. changes in counterregulatory body’s insulin production increases after each meal hormonal responses to procedures or illnesses. (Table). scheduled subcutaneous exacerbation of myocardial and cerebral ischemia. may not have long-term nonecritically ill patient in the hospital. with consumption of carbohydrates. such as prevents ketosis in insulinopenic patients (patients computed tomography scans. unexpected decreases in food intake or emesis. use of quinolone antibiotics. bringing serum glucose doses of dextrose fluids or glucocorticoid therapy. with many extraneous insulin injectable medications. In the hospital setting.1 Diagnostic tests. can put the patient taking metformin at risk of diabetes) and. which suppresses glucose production by such as glargine. Even with prolonged fasting. pancreas. below 50-60 mg/dL. such as the glucagon. or worsening of hepatic or renal function. Moreover.1 There is a sequelae. Basal insulin chronic pulmonary disease. blood glucose rarely falls interruption of enteral or parenteral nutrition. May 2015 . or could trigger arrhythmias or other cardiac hyperglycemia while avoiding hypoglycemia is the events. oral agents and non-insulin Hyperglycemia in the hospital (blood glucose injectable medications may be resumed at discharge > 140 mg/dL) can increase the risk of infections. Despite being discontinued control. if used properly. which can lead to severe. and subsequent gluconeogenesis. or intermediate-acting the liver. and possibly prolong the length of before hospitalization. will manage fasting 532 The Journal for Nurse Practitioners . electrolyte imbalances. may be contraindicated doses are paramount. part B). hospital include variability in insulin sensitivity related With normal endogenous insulin secretion. prolonged hy- poglycemia. who are stable.5 Possible causes of hypoglycemia in the primary goal. detemir. Also. Basal-Bolus Insulin Therapy tients with poor appetite or impaired renal function.6 Basal insulin therapy. and may pre. if brief and mild. and have no hospital stay. the appropriate types and timing of insulin like peptide 1 analogs. the use of non. Providers endogenous insulin secretion is present to metabolize should be proactive in reducing insulin doses in hepatic glucose production. physiologic response requires an understanding of insulin MANAGEMENT OF HYPERGLYCEMIA pharmacodynamics. levels back to within a normal range (Figure. Understanding this such settings. Hyperglycemia has been associated with contraindications. variable malizes between meals. acidosis. are decompensated heart failure. renal insufficiency. Sulfonylureas act by circumstances and the current clinical condition of increasing insulin release from islet cells in the the patient. sepsis. Prudent treatment of seizures. or usually given once or twice daily.improvement in mortality with intensive glycemic renal failure or lactic acidosis.2 insulin with basal. and correction compo- Conversely. due to hepatic glycogenolysis concurrent malignancy. pharmacodynamics of types of insulin have differences dispose patients to hypoglycemia. endothelial dysfunction. part A). The and efficacy in hospitalized patients. Insulin impairment of neutrophil function. oxidative stress. variables. as is consideration of the in many inpatient settings. Long-acting basal insulins.

or twice daily Basal insulin is usually administered at bedtime HS. or for patients who have daily. hypoglycemia. and any other rapid-acting analog could be substituted for aspart. medical insurance. it can be effective in hospitalized patients insulins cost less than the analog mixes (Humalog receiving nocturnal tube feedings. hepatic glucose production. (A) Normal glucose-insulin postprandial excursions. NPH analog insulins (lispro. Hepatic glucose production sustains glycemia during the fasting state. The example shows a subcutaneous basal-bolus insulin regimen matching meal intake and fasting glucose hepatic production. start of tube feeding in the hospital. has been associated with an increased risk of and glargine). (B) Multiple daily injections of insulin. and (Table).6 It combination premixed insulins is their lack of dosing may be used twice daily in patients receiving flexibility.JNP 533 . A disadvantage of using renal failure can prevent nocturnal hypoglycemia. or at acting basal insulin] and 30% regular insulin human the time of bolus tube feedings. or other the long-acting analogs glargine or detemir. Fasting glucose levels are [short-acting insulin]). can be administered at the the best indicator of an adequate basal insulin dose. prescription drug coverage. but detemir could be substituted for glargine.npjournal. The example shows a postprandial glucose excursion and superimposed insulin action compares rapid- acting aspart insulin to short-acting regular insulin. Bolus insulin (also Novolin or Humulin 70/30 mixed insulin (70% referred to as prandial or nutrition insulin) is usually isophane insulin human suspension [intermediate. such as Bolus insulin therapy. given just before meals or at mealtimes (AC). (C) Insulin action and duration. NPH has limited use in the hospital setting. before breakfast and before dinner in hospitalized but administering it in the morning in patients with patients who are eating. or for enhanced absorption in those daily injections and who prefer 2 rather than 4 requiring large doses (> 100 units) of basal insulin daily insulin injections. Combination premixed However. with concurrent endogenous insulin responses (red dotted line) are shown. Glargine and aspart are used as insulin examples. detemir. aspart. Compared with Mix 75/25 and NovoLog Mix 70/30). They could be an option at discharge for continuous nutrition (parenteral or continuous tube patients who are on an insulin program of multiple feedings). glulisine. The rapid-acting www.org The Journal for Nurse Practitioners . Because of its pharmacodynamic profile limited financial resources.Figure. The normal postprandial blood glucose excursions in fasting glucose levels over a 24-hour period (solid blue line). Combination insulins.

a The metabolic effect of various insulins (peaks. and they can basal and prandial insulin components. part C). b Insulin analog. insulin sensitivity factor for regular insulin. Correction scales based on result in wide swings in glucose levels throughout insulin sensitivity can be mild (for frail. insulin-resistant patients on an insulin doseefinding strategy before an individu- high-dose steroids). be useful in renal insufficiency). treating hyperglycemia. and they instead are using a basal-bolus insulin regimen to improve CORRECTION INSULIN THERAPY inpatient glucose control. It can serve as aggressive (for obese. or the hospital setting is neither recommended nor lispro) over short-acting regular insulin because of effective. thin. The Correction insulin is intended to lower high sensitivity factor shows how far blood sugar will glucose levels.7 Using correction insulin alone in the total daily dose (TDD) of insulin ¼ correction 534 The Journal for Nurse Practitioners .” which calculates the correction insulin is also administered at HS. in the hospital. In the hospital setting. or for patients with Correction scale insulin can.Table. findings. the hospitalization period. if needed. and hyperglycemia in inpatients. and it may be detrimental much food they will actually consume (eg. onsets. which may above a certain target. As a result of previous testing is usually ordered at mealtimes and at bedtime. is to use the “Rule of 1500. insulin-sensitive patients. ally appropriate basal-bolus program can be deter- directed. based on the particular situation of the mined and started. Correction insulin. elderly. patients to glucose control. or individually provider. May 2015 . insulin) is administered to correct a glucose level glycemic control is often not assessed.8 A physiologic insulin regimen is indeed their quicker onset and shorter duration and because superior to a standardized insulin sliding scale for they more closely match mealtime glucose excursions management of hyperglycemia in hospitalized (Figure. moderate (for most patients). insulin analogs are preferred (aspart. many hospitals are not using correction Scheduled prandial insulin is ordered for mealtimes to insulin as a stand-alone therapy for treating diabetes cover the carbohydrates consumed.JNP Volume 11. min ¼ minutes.3. NPH ¼ neutral protamine Hagedorn. rather than a proactive or fingerstick point-of-care capillary blood glucose an anticipatory approach. and durations) are shown. Prandial insulin analogs can be dosed patients. Using correction insulin alone. the first 24-48 hours of hospitalization. It is a reactive approach to with nausea or gastroparesis). puts be given before or immediately after the meal for patients with type 1 diabetes and insulin deficiency patients who may not be sure before the meal how at risk for ketoacidosis. glulisine. Ranges account for patient variability. without by the amount of carbohydrates eaten. however. not to cover nutritional glucose decrease per unit of regular insulin: 1500 divided by intake. is A general guideline for calculating insulin usually added to the scheduled prandial dose for a sensitivity to select an appropriate correction scale single injection.9 When correction scales Correction insulin (also known as sliding scale are used alone for several days (one size fits all). Insulin Pharmacodynamicsa Type of Insulin Trade Name Onset Peak Duration Ultrafast-acting Technosphere insulin Instant 15-20 min 2-3 h (Afrezza) (inhaled)b Rapid-acting Lispro (Humalog)b 10-15 min 45-60 min 3-5 h Aspart (NovoLog)b Glulisine (Apidra)b Short-acting Regular 30-60 min 2-4 h 4-8 h Intermediate-acting NPH 1-2 h 6-10 h 20-24 h b Long-acting Detemir (Levemir) 2h Small 24 h Glargine (Lantus)b 2h None 24 h h ¼ hours. Sometimes. individual patient. Issue 5.

eating well on a basal-bolus insulin regimen. Humalog. The result When using an analog insulin. The correction scale of an IV insulin infusion occur in patients with un- insulin is continued (rapid-acting or short-acting) to controlled blood glucose (> 400 mg/dL). 3 Correction insulin is usually administered intermit. weight (in kilograms) by 0.5). posteorgan transplant patients on daily. Instead of a separate basal insulin in. and one half of the TDD is the basal in- correction factor would be 1800 / 40 or 45.org The Journal for Nurse Practitioners . Then divide 50 with 40 units of TDD (eg. may result in better glucose control. The will decrease faster with analog insulins. for patients NPO. to optimize lished. can be incorporated as short-acting regular glucose control during the hospitalization. basal TPN (IV nutrition bypasses the intestinal regulators insulin should be titrated daily by 10%-20% until the of glucose metabolism). NPH.7 Any scheduled basal insulin that was received by the patient in the 24 hours before IV INSULIN INFUSIONS TPN was initiated can be incorporated into the TPN IV insulin infusions are often used in the intensive bag as well (as regular insulin). diabetic supplement the insulin in the TPN bag. This rule is TDD ¼ patient weight (in kilograms)  0. Indications for use glargine) is then discontinued. the first time. with 1800 divided by the TDD of insulin ¼ correction 50% of the dose being the basal requirement and 50% factor/insulin sensitivity. patients admitted on www. the glucoses are at goal range. and the rule of 1800 is 50 units as the TDD of insulin. the scheduled prandial insulin should not be who are NPO on continuous tube feedings. if necessary. Order an appropriate correction scale us- glucose of patients on continuous TPN therapy every ing rapid-acting insulin for AC and HS to be 4 hours. hydrate in the bag. multiply lar). also be titrated daily by 10%-20% until the pre-meal jection administered concurrently with the TPN.npjournal. This prandial and basal insulins. or Apidra) because blood sugar calculation can be used as a starting point. that is. The scheduled care unit to attain optimal glucose control in patients subcutaneous basal insulin (eg. of the dose being the prandial requirement.1 unit of regular insulin for every gram of carbo. which is also often high in fasting glucose is at goal.10 When an inpatient (who is not transitioning off an The “Rule of 1800” was later developed to show insulin drip) is started for the first time on a basal- the sensitivity factor per unit of analog insulin bolus insulin regimen in the hospital. As an example. detemir. every opportunity throughout the patient’s hospital- When initially adding insulin to the TPN bag for ization to make an insulin adjustment. NPH þ regu.5 (100  0. the correction factor would be 1500 / 40 or 38. NPH þ NovoLog). a good starting point would be to add will help to determine the most accurate insulin doses 0. sulin requirement (25 units) and the other half is the prandial requirement (25 units). and bedtime glucose is total daily basal requirement of insulin.JNP 535 . those having cardiac surgery. times a day. at the time of discharge.5. when using the rule of 1500 with To start a 220-pound (100-kg) patient who is 40 units of TDD insulin per day (eg. the units by 2. postemyocardial infarct patients or during the previous 24-hour period. which equals the interval in a correction INITIAL START OF INSULIN scale (also known as the insulin sensitivity). and hyperosmolar hyperglycemic non- insulin incorporated into the TPN bag is adjusted ketotic syndrome.factor. once estab. Using insulin into the TPN bag. < 180 mg/dL (preferably < 140 mg/dL). The prandial insulins should carbohydrates. Checking the capillary (25 units). a weight-based (NovoLog. or with glucose levels > 180 mg/dL. The prandial doses TPN AND INSULIN should be ordered as 8 units with each meal. depending on the additional rapid-acting or high-dose corticosteroids in the immediate post- short-acting correction insulin used by the patient operative period. If that same patient were to be made tently (4-6 times daily). The TDD of ketoacidosis. Because of the current is because of the loss of incretin effect with the use of limited length of stay of hospitalized patients. or on ordered. and using correction insulin if necessary at administered concomitantly with the scheduled those times. if necessary. the patient would have just the basal insulin parenteral nutrition or TPN.

536 The Journal for Nurse Practitioners . body weight. May 2015 . 24-hour period. and titration of the insulin. (24-hour) basal insulin requirement. IV insulin algorithms are the other half is administered at bedtime that eve- standardized guidelines for dose adjustment that are ning. is recovering from infusion to subcutaneous insulin. if nutritional status. One half of necessary. reducing the amount of algorithm that has been studied extensively. or any other medications that sulin drip and administration of subcutaneous basal would affect glucose levels. If the patient has not been eating commander (Glytec LLC) as a method of maintaining 100% of their meals but has been eating some while IV glucose control. hourly blood glucose testing and rate adjustment. Appropriate doses may hours after the first subcutaneous injection of basal depend on the degree of illness. concomitant medication dose changes. computer-directed on the IV insulin infusion. multiply 6 (hours) ready for the transition from IV to subcutaneous  4 (units/hour) ¼ 24 units. then divided by 2 ¼ 38 units). vasopressors. because of the steady state TDD would be 48 units for basal and 48 units for of IV insulin infusion over the previous 6 hours. Provider discretion and clinical judgment disconnected). All patients with type 1 or type 2 diabetes (units)  4 ¼ 96 units to determine the total daily mellitus should be transitioned to subcutaneous long. in this state and insulin requirements of the patient for a case. Consider acting or intermediate-acting insulin at least 2 hours ordering about 80% of this amount if the patient is before discontinuation of the IV insulin infusion. or postebariatric surgery 50% total prandial dose value would then be divided patients) to more aggressive (for morbidly obese by 3 for a scheduled dose of insulin at each mealtime or insulin-resistant patients or those on high doses of the day. If this same patient had been eating 100% of by 4 to calculate the TDD of basal insulin require. type 1 dia. depending on the clinical situation of the postoperative period. the 96 units ment. and the insulin drip who has not been eating while on the drip. then 38 units of basal the transition period. Issue 5. from mild (for frail.JNP Volume 11.11 Consider this example of transitioning a stable If the patient is clinically stable. The betic. the intensive care unit. reasonable to add up the hourly infusion rates (per The nighttime basal insulin dose would also be 38 hour) over the previous 6 hours. and then multiply 24 insulin. insulin would be ordered once (80% of 96 units ¼ 77 When transitioning a stable inpatient off an insulin units. post-pancreatectomy. elderly. and it scheduled prandial insulin by 10%-20% would be can be effective throughout the hospital. it is infusion would be continued for another 2 hours. It is a safe. not just in reasonable. is beginning to eat regular meals. The insulin drip is typically discontinued 2 based on the glucose level. If ordering 80% of the insulin is to prevent recurrent hyperglycemia during total basal insulin requirement. he or she may be hour over the previous 6 hours. 50% prandial insulin and 50% basal insulin doses. not as acutely ill and if doses are to be decreased for This overlap between the discontinuation of the in. and severity of illness). for AC and HS. and post-pancreatectomy patients to can dictate whether the TDD could be reduced by determine insulin requirements in the immediate 10%-20%. or insulin. They can be effective at keeping glucose the TDD of basal insulin is administered subcutane- levels in the targeted ranges. or is been receiving a stable rate of 4 units of insulin per transferred to a general nursing unit. steroids. and the prandial insulin the average hourly rate over the previous 6 hours and would be 16 units 3 times per day with meals. If the patient was eating while on the insulin medications. If the total insulin value will probably best reflect the current clinical requirement was not being decreased by 80%. If the patient has critical illness. and then multiply units. IV insulin infusions require patient (eg. this prandial insulin requirements. has reached a patient who has been NPO from an IV insulin steady state of glucose control. and they allow for easy ously at the time of transition off the insulin drip. the basal insulin would be 24 units once. Another option would be to take another 24 units at bedtime. Many hospitals use predetermined infusion. Some facilities are using Glu. their meals while on the insulin infusion. A correction insulin scale is also ordered of glucocorticoids).insulin pumps undergoing certain types of surgery multiply that by 24 to obtain the TDD of basal involving high doses of steroids (the insulin pump is insulin. the TDD value should be divided into algorithms. The premise is that.

Glucose normalization and subcutaneous insulin infusion. Boyle ME. Jt Comm J Qual Patient Saf.29(1):36-39. Can J Hosp Pharm. many institutions are allowing patients to remain home health referral should be considered for the on these devices during their hospitalization. Johnston JM. Hypoglycaemia and CV risk: perceptions and reality. Diabetes Metab Syndr. Murphy DM. 2014.016 www.1016/j. Both authors are affiliated with the Division of Endocrinology at bolus. Throughout the outcomes in patients with acute myocardial infarction.26(3):589-598. and resources in the community should be including during some types of surgery. Mackey PA. 6. Curr Med Res Opin. Matson AW. http://dx. Beer KA. 2012. Dinsmoor RS.1 Continued use of correction insulin scales patricia@mayo. ahead of print]. hospitalization. http://www. A apy. Michael D. assessments of infusion site. Karounos DG. [Epub record.com/Articles/Diabetes actively in the hospital setting. Cook CB. http://dx. Frequent and -Definitions/insulin_sensitivity_factor/. Mayo Clinic College of Medicine. glucose control in nonecritically ill hospitalized Mayo Clinic College of Medicine and can be reached at mackey.org/10. delineating the inpatient guidelines for continuous 2012. Hellman R. Clin Diabetes. Mackey.doi. Inpatient management of hyperglycemia and diabetes.35(4):216-223. 2009. Brommecker F.dsx. FRCPC. AZ. Data continue to accumulate regarding adverse 8.INSULIN PUMP THERAPY Follow-up after hospital discharge requires planning With the increased utilization of insulin pump ther. to provide a smooth transition to outpatient care.021. et al. Ghosal S.64(5):333-339. majority of hospitalized patients. Am J Health Syst Pharm.2015. accurately documented in the patient’s medical 5.edu. 2009. Overall. 2013.JNP 537 . Umpierrez GE. not recommended. Bertucci TM. Korytkowski MT. Chen HJ. et al. Maynard G. Adhikari NK. 2011. Cobaugh DJ. Management of hyperglycemia in hospitalized patients in non-critical care setting: an The hospital should have a policy and procedures endocrine society clinical practice guideline. Insulin sensitivity factor. Reducing hyperglycemia pump settings.169(5):438-446. Ann Pharmacother. Whitaker. glycemia in the hospitalized patient.2013. Vercruysse RA. Silverberg J.1016/j. Arch Intern Med.10. 2014. 21. is alone as a method of controlling hyperglycemia is a consultant in endocrinology.doi. Moghissi ES. BC-ADM.6(5):995-1002. and correction insulin regimen is the the Mayo Clinic in Scottsdale. as is judi. and careful imple- mentation of standardized approaches to help ensure 1555-4155/15/$ see front matter © 2015 Elsevier.02. consensus panel.diabetesselfmanagement. et al. education of all or industry that would pose a conflict of interest. Enhancing insulin-use safety in hospitals: practical recommendations from an ASHP Foundation expert effects of poorly controlled diabetes and hyper. Standards of medical care in diabetes: 2014. Ng E. A subcutaneous basal.70(16):1404-1413. Institutions 9. J Clin Endocrinol Metab.npjournal. Diabetes self-management. Castro JC.44(2):249-556. Outpatient diabetes self-management is who use continuous subcutaneous insulin infusion in critical to minimizing risks of future complications. the authors report no relationships with business requires ongoing team efforts. glucose targets near 140 mg/dL Transitioning insulin pump therapy from the outpatient to the inpatient setting: a review of 6 years’ experience with 253 cases. February ways to manage diabetes and hyperglycemia pro. Sinha B. hypoglycemia. Intensive insulin protocol implementation and outcomes in the medical and surgical wards at a worldwide are striving to develop safe and effective Veterans Affairs Medical Center. 3.org The Journal for Nurse Practitioners . 10. 4. and insulin re- mains the most appropriate agent for management of inpatient hyperglycemia. Inc. multidisciplinary team members. Patricia A. patient. 11. Diabetes Care. Kosiborod M. 2. MD. All rights reserved. Krumholz HM.org/10. CDE.nurpra. FNP- preferred method of achieving and managing BC. J Diabetes Sci are recommended as the most appropriate for the Technol. of the glucommander method of adjusting insulin infusions in critically ill patients. In compliance with national Glycemic management of hospitalized patients ethical guidelines.12 Patients identified. Steinke DT. Implementation effective glucose monitoring is critical. CONCLUSION 7. et al. if they have the physical and mental capacity to do so. Addressing hyperglycemia from hospital admission to discharge. 2010. Seifert KM. Magaji V. is an assistant professor of medicine. Inzucchi SE. assistant professor of Medicine. basal rates. barring no contraindications and 1. American Diabetes Association. and bolus insulin doses should be hospitalwide: the basal-bolus concept. 2013. 2011. the outpatient setting can be considered candidates for continuation of their insulin pump throughout References their hospitalization. Cooper L.97(1):16-38. patient safety and promote the best possible outcomes. patients. Yamashita S. Lane MT. 2010. cious treatment of hyperglycemia while avoiding 12.37(Suppl 1):S14-S80. Accessed October 9.