Professional Documents
Culture Documents
ADA - Diabetes Care in The Hospital. Standards of Care in Diabetes 2023. ElSayed N 2023
ADA - Diabetes Care in The Hospital. Standards of Care in Diabetes 2023. ElSayed N 2023
Recommendations
16.1 Perform an A1C test on all people with diabetes or hyperglycemia (blood
glucose >140 mg/dL [7.8 mmol/L]) admitted to the hospital if not per-
formed in the prior 3 months. B
16.2 Insulin should be administered using validated written or computerized Disclosure information for each author is
protocols that allow for predefined adjustments in the insulin dosage available at https://doi.org/10.2337/dc23-SDIS.
based on glycemic fluctuations. B Suggested citation: ElSayed NA, Aleppo G,
Aroda VR, et al., American Diabetes Association.
16. Diabetes care in the hospital: Standards of Care
Considerations on Admission in Diabetes—2023. Diabetes Care 2023;46(Suppl. 1):
S267–S278
High-quality hospital care for diabetes requires standards for care delivery, which are
best implemented using structured order sets and quality improvement strategies for © 2022 by the American Diabetes Association.
process improvement. Unfortunately, “best practice” protocols, reviews, and guide- Readers may use this article as long as the
work is properly cited, the use is educational
lines (2,4) are inconsistently implemented within hospitals. To correct this, medical and not for profit, and the work is not altered.
centers striving for optimal inpatient diabetes treatment should establish protocols More information is available at https://www.
and structured order sets, which include computerized provider order entry (CPOE). diabetesjournals.org/journals/pages/license.
S268 Diabetes Care in the Hospital Diabetes Care Volume 46, Supplement 1, January 2023
Initial orders should state the type of Appropriately trained specialists or spe- Standard Definitions of Glucose
diabetes (i.e., type 1, type 2, gestational cialty teams may reduce the length of Abnormalities
diabetes mellitus, pancreatogenic diabetes) stay and improve glycemic and other clini- Hyperglycemia in hospitalized patients is de-
when it is known. Because inpatient treat- cal outcomes (21–23). In addition, the fined as blood glucose levels >140 mg/dL
ment and discharge planning are more ef- increased risk of 30-day readmission fol- (7.8 mmol/L) (33). Blood glucose levels
fective if based on preadmission glycemia, lowing hospitalization that has been at- persistently above this level warrant prompt
A1C should be measured for all people tributed to diabetes can be reduced, and interventions, such as alterations in nu-
with diabetes or hyperglycemia admit- costs saved when inpatient care is pro- trition or changes to medications that
ted to the hospital if an A1C test has not vided by a specialized diabetes manage- cause hyperglycemia. An admission A1C
been performed in the previous 3 months ment team (21,24,25). In a cross-sectional value $6.5% (48 mmol/mol) suggests that
(5–8). In addition, diabetes self-manage- study comparing usual care to specialists the onset of diabetes preceded hospitaliza-
ment knowledge and behaviors should reviewing diabetes cases and making tion (see Section 2, “Classification and
recommendations virtually through the Diagnosis of Diabetes”) (33,34). Hypoglyce-
significantly higher mortality (27.5% vs. More frequent POC blood glucose moni- teams allow the use of CGM in selected
25%). The intensively treated group had toring ranging from every 30 min to every people with diabetes on an individual ba-
10- to 15-fold greater rates of hypoglyce- 2 h is the required standard for safe use sis, mostly in noncritical care settings, pro-
mia, which may have contributed to the of intravenous insulin. Safety standards vided both the individual and the glucose
adverse outcomes noted. The findings for blood glucose monitoring that prohibit management team are well educated in
from NICE-SUGAR are supported by sev- sharing lanceting devices, other testing the use of this technology. CGM is not cur-
eral meta-analyses and a randomized con- materials, and needles are mandatory (45). rently approved for intensive care unit use
trolled trial, some of which suggest that The vast majority of hospital glucose due to accuracy concerns such as hypovo-
tight glycemic management increases monitoring is performed with FDA-approved lemia, hypoperfusion, and use of therapies
mortality compared with more moder- prescription POC glucose monitoring sys- such as vasopressor agents.
ate glycemic targets and generally causes tems with and capillary blood taken from During the coronavirus disease 2019
higher rates of hypoglycemia (38–40). finger sticks, similar to the process per- (COVID-19) pandemic, many institutions
written or computerized protocols that safer procedure is administering pran- help minimize hyperglycemia and avoid
allow for predefined adjustments in the dial insulin immediately after eating, rebound hypoglycemia (83,84). The dose
infusion rate, accounting for glycemic with the dose adjusted to be appropriate of basal insulin is best calculated on the
fluctuations and insulin dose (64). for the amount of carbohydrates ingested basis of the insulin infusion rate during
(71). the last 6 h when stable glycemic goals
Noncritical Care Setting A randomized controlled trial has shown were achieved (85). For people being transi-
In most instances, insulin is the pre- that basal-bolus treatment improved glyce- tioned to concentrated insulin (U-200,
ferred treatment for hyperglycemia in mic outcomes and reduced hospital com- U-300, or U-500) in the inpatient setting,
hospitalized patients. However, in certain plications compared with a correction or it is important to ensure correct dosing
circumstances, it may be appropriate to supplemental insulin without basal insulin by utilizing an individual pen or cartridge
continue home therapies, including oral (formerly known as sliding scale) in general for each person and by meticulous phar-
glucose-lowering medications (64,65). If surgery for people with type 2 diabetes macy and nursing supervision of the dose
16.10 Treatment regimens should the hospital (103), possibly as a result the risk for a subsequent event, partly
be reviewed and changed as of decreased insulin clearance. Studies because of impaired counterregulation
necessary to prevent further of “bundled” preventive therapies, includ- (108,109). This relationship also holds
hypoglycemia when a blood ing proactive surveillance of glycemic true for people with diabetes in the in-
glucose value of <70 mg/dL outliers and an interdisciplinary data- patient setting. For example, in a study of
(3.9 mmol/L) is documented. C driven approach to glycemic management, hospitalized individuals treated for hyper-
showed that hypoglycemic episodes in glycemia, 84% who had an episode of
the hospital could be prevented. Com- “severe hypoglycemia” (defined in the
People with or without diabetes may pared with baseline, two such studies study as <40 mg/dL [2.2 mmol/L]) had
experience hypoglycemia in the hospital found that hypoglycemic events fell by a preceding episode of hypoglycemia
setting. While hypoglycemia is associated 56–80% (99,104,105). The Joint Commis- (<70 mg/dL [3.9 mmol/L]) during the
with increased mortality (97), in many sion recommends that all hypoglycemic same admission (110). In another study
the menu at any time during the day. This STANDARDS FOR SPECIAL nutrition bag is the safest way to prevent
option improves patient satisfaction but SITUATIONS hypoglycemia if the parenteral nutrition
complicates meal-insulin coordination. Enteral/Parenteral Feedings is stopped or interrupted. Correctional
Finally, if the hospital food service sup- For individuals receiving enteral or par- insulin should be administered subcu-
ports carbohydrate counting, this option enteral feedings who require insulin, taneously to address any hyperglyce-
should be made available to people the insulin orders should include cover- mia. For full enteral/parenteral feeding
with diabetes counting carbohydrates age of basal, prandial, and correctional guidance, please refer to review articles
at home (115,116). needs (115,122,123). It is essential that detailing this topic (122,124,125).
people with type 1 diabetes continue to Because continuous enteral or paren-
SELF-MANAGEMENT IN THE receive basal insulin even if feedings are teral nutrition results in a continuous
HOSPITAL discontinued. postprandial state, efforts to bring blood
Diabetes self-management in the hospi- Most adults receiving basal insulin glucose levels to below 140 mg/dL
improved time in range (70–180 mg/dL); insulin analogs on glycemia in periop- (146). Individuals with uncomplicated
however, there was an increase in hypo- erative care. DKA may sometimes be treated with
glycemia (133). Whatever insulin orders subcutaneous insulin in the emergency
are initiated, daily adjustments based on A recent review concluded that peri- department or step-down units (147).
levels of glycemia and anticipated changes operative glycemic targets tighter than This approach may be safer and more
in type, doses, and duration of glucocorti- 80–180 mg/dL (4.4–10.0 mmol/L) did cost-effective than treatment with intra-
coids, along with POC blood glucose moni- not improve outcomes and was asso- venous insulin. If subcutaneous insulin
toring, are critical to reducing rates of ciated with more hypoglycemia (137); administration is used, it is important to
hypoglycemia and hyperglycemia. therefore, in general, stricter glycemic provide an adequate fluid replacement,
targets are not advised. Evidence from frequent POC blood glucose monitoring,
Perioperative Care a recent study indicates that compared treatment of any concurrent infections,
It is estimated that up to 20% of general with usual dosing, a reduction of insulin and appropriate follow-up to avoid re-
within 1 month of discharge is advised place increases the likelihood that care reduce readmission rates (151,155).
for all individuals experiencing hyper- they will attend. While there is no standard to prevent re-
glycemia in the hospital. If glycemic admissions, several successful strate-
medications are changed or glucose It is recommended that the following gies have been reported (151). These
management is not optimal at discharge, areas of knowledge be reviewed and ad- include targeting ketosis-prone people
an earlier appointment (in 1–2 weeks) is dressed before hospital discharge: with type 1 diabetes (157), insulin treat-
preferred, and frequent contact may be ment of individuals with admission A1C
needed to avoid hyperglycemia and • Identification of the health care pro- >9% (75 mmol/mol) (158), and the use
hypoglycemia. A discharge algorithm fessionals who will provide diabetes of a transitional care model (159). For
for glycemic medication adjustment based care after discharge. people with diabetic kidney disease, col-
on admission A1C, diabetes medications • Level of understanding related to the laborative patient-centered medical
before admission, and insulin usage diabetes diagnosis, glucose monitor- homes may decrease risk-adjusted re-
11. Garg R, Schuman B, Bader A, et al. Effect of 27. Endocrine Society. Clinical Practice Guidelines. GLUCO-CABG trial. Diabetes Care 2015;38:1665–
preoperative diabetes management on glycemic Accessed 30 August 2022. Available from https:// 1672
control and clinical outcomes after elective surgery. www.endocrine.org/clinical-practice-guidelines 41. Furnary AP, Wu Y, Bookin SO. Effect of
Ann Surg 2018;267:858–862 28. Magee MF, Baker KM, Bardsley JK, Wesley D, hyperglycemia and continuous intravenous insulin
12. van den Boom W, Schroeder RA, Manning Smith KM. Diabetes to go-inpatient: pragmatic infusions on outcomes of cardiac surgical
MW, Setji TL, Fiestan GO, Dunson DB. Effect of lessons learned from implementation of technology- procedures: the Portland Diabetic Project. Endocr
A1C and glucose on postoperative mortality in enabled diabetes survival skills education within Pract 2004;10(Suppl. 2):21–33
noncardiac and cardiac surgeries. Diabetes Care nursing unit workflow in an urban, tertiary care 42. Low Wang CC, Draznin B. Practical approach
2018;41:782–788 hospital. Jt Comm J Qual Patient Saf 2021;47: to management of inpatient hyperglycemia in
13. Setji T, Hopkins TJ, Jimenez M, et al. 107–119 select patient populations. Hosp Pract (1995)
Rationalization, development, and implementation 29. Pinkhasova D, Swami JB, Patel N, et al. 2013;41:45–53
of a preoperative diabetes optimization program Patient understanding of discharge instructions 43. Magaji V, Nayak S, Donihi AC, et al.
designed to improve perioperative outcomes and for home diabetes self-management and risk for Comparison of insulin infusion protocols targeting
reduce cost. Diabetes Spectr 2017;30:217–223 hospital readmission and emergency department 110–140 mg/dL in patients after cardiac surgery.
14. Okabayashi T, Shima Y, Sumiyoshi T, et al. visits. Endocr Pract 2021;27:561–566 Diabetes Technol Ther 2012;14:1013–1017
COVID-19: results of an emergent pilot study. J 72. Dhatariya K, Corsino L, Umpierrez GE. primary medical and surgical teams. Cleve Clin
Diabetes Sci Technol 2020;14:1065–1073 Management of diabetes and hyperglycemia J Med 2016;83(Suppl. 1):S34–S43
57. Galindo RJ, Aleppo G, Klonoff DC, et al. in hospitalized patients. In: Feingold KR, Anawalt B, 87. Umpierrez GE, Gianchandani R, Smiley D,
Implementation of continuous glucose moni- Boyce A, et al., Eds. Endotext. South Dartmouth, et al. Safety and efficacy of sitagliptin therapy for
toring in the hospital: emergent considerations MA, MDText.com, Inc. Accessed 30 August 2022. the inpatient management of general medicine
for remote glucose monitoring during the Available from https://www.ncbi.nlm.nih.gov/ and surgery patients with type 2 diabetes: a pilot,
COVID-19 pandemic. J Diabetes Sci Technol 2020; books/NBK279093/ randomized, controlled study. Diabetes Care 2013;
14:822–832 73. Sadhu AR, Patham B, Vadhariya A, 36:3430–3435
58. Agarwal S, Mathew J, Davis GM, et al. Chikermane SG, Johnson ML. Outcomes of 88. Pasquel FJ, Fayfman M, Umpierrez GE.
continuous glucose monitoring in the intensive “real-world” insulin strategies in the management Debate on insulin vs non-insulin use in the
care unit during the COVID-19 pandemic. Diabetes of hospital hyperglycemia. J Endocr Soc 2021; hospital setting-is it time to revise the guidelines
Care 2021;44:847–849 5:bvab101 for the management of inpatient diabetes? Curr
59. Faulds ER, Jones L, McNett M, et al. 74. Umpierrez GE, Smiley D, Jacobs S, et al. Diab Rep 2019;19:65
Facilitators and barriers to nursing implementation Randomized study of basal-bolus insulin therapy 89. Pasquel FJ, Lansang MC, Dhatariya K,
of continuous glucose monitoring (CGM) in critically in the inpatient management of patients with Umpierrez GE. Management of diabetes and
algorithm in the inpatient setting. Hosp Pract 116. Draznin B. Food, fasting, insulin, and vincristine, and dexamethasone chemotherapy.
(1995) 2016;44:260–265 glycemic control in the hospital. In Managing Diabetes Technol Ther 2014;16:874–879
100. Amori RE, Pittas AG, Siegel RD, et al. Diabetes and Hyperglycemia in the Hospital 132. Cheng YC, Guerra Y, Morkos M, et al.
Inpatient medical errors involving glucose- Setting. Alexandria, VA, American Diabetes Insulin management in hospitalized patients with
lowering medications and their impact on Association, 2016, p. 70–83 diabetes mellitus on high-dose glucocorticoids:
patients: review of 2,598 incidents from a 117. Mabrey ME, Setji TL. Patient self-manage- management of steroid-exacerbated hyper-
voluntary electronic error-reporting database. ment of diabetes care in the inpatient setting: glycemia. PLoS One 2021;16:e0256682
Endocr Pract 2008;14:535–542 pro. J Diabetes Sci Technol 2015;9:1152–1154 133. Bajaj MA, Zale AD, Morgenlander WR,
101. Alwan D, Chipps E, Yen PY, Dungan K. 118. Shah AD, Rushakoff RJ. Patient self- Abusamaan MS, Mathioudakis N. Insulin dosing
Evaluation of the timing and coordination of management of diabetes care in the inpatient and glycemic outcomes among steroid-treated
prandial insulin administration in the hospital. setting: con. J Diabetes Sci Technol 2015;9: hospitalized patients. Endocr Pract 2022;28:
Diabetes Res Clin Pract 2017;131:18–32 1155–1157 774–779
102. Korytkowski M, Dinardo M, Donihi AC, Bigi L, 119. Yeh T, Yeung M, Mendelsohn Curanaj FA. 134. Todd LA, Vigersky RA. Evaluating peri-
Devita M. Evolution of a diabetes inpatient safety Managing patients with insulin pumps and operative glycemic control of non-cardiac
committee. Endocr Pract 2006;12(Suppl. 3):91–99 continuous glucose monitors in the hospital: to surgical patients with diabetes. Mil Med 2021;
147. Kitabchi AE, Umpierrez GE, Fisher JN, 152. Rinaldi A, Snider M, James A, et al. The 157. Maldonado MR, D’Amico S, Rodriguez L,
Murphy MB, Stentz FB. Thirty years of personal impact of a diabetes transitions of care clinic Iyer D, Balasubramanyam A. Improved outcomes
experience in hyperglycemic crises: diabetic on hospital utilization and patient care. Ann in indigent patients with ketosis-prone diabetes:
ketoacidosis and hyperglycemic hyperosmolar Pharmacother. 9 June 2022 [Epub ahead of print]. effect of a dedicated diabetes treatment unit.
state. J Clin Endocrinol Metab 2008;93:1541–1552 DOI: 10.1177/10600280221102557 Endocr Pract 2003;9:26–32
148. Karajgikar ND, Manroa P, Acharya R, et al. 153. Patel N, Swami J, Pinkhasova D, et al. Sex 158. Wu EQ, Zhou S, Yu A, Lu M, Sharma H, Gill J,
Addressing pitfalls in management of diabetic differences in glycemic measures, complications, et al. Outcomes associated with post-discharge
ketoacidosis with a standardized protocol. Endocr discharge disposition, and postdischarge emergency insulin continuity in US patients with type 2
Pract 2019;25:407–412 room visits and readmission among non-critically diabetes mellitus initiating insulin in the hospital.
149. Dhatariya KK, Glaser NS, Codner E, ill, hospitalized patients with diabetes. BMJ Open Hosp Pract (1995) 2012;40:40–48
Umpierrez GE. Diabetic ketoacidosis. Nat Rev Dis Diabetes Res Care 2022;10:e002722 159. Hirschman KB, Bixby MB. Transitions in care
Primers 2020;6:40 154. Agency for Healthcare Research and Quality. from the hospital to home for patients with
150. Shepperd S, Lannin NA, Clemson LM, Patient Safety Network – Readmissions and adverse diabetes. Diabetes Spectr 2014;27:192–195
McCluskey A, Cameron ID, Barras SL. Discharge events after discharge, 2019. Accessed 23 October 160. Tuttle KR, Bakris GL, Bilous RW, et al.
planning from hospital to home. Cochrane Database 2022. Available from https://psnet.ahrq.gov/ Diabetic kidney disease: a report from an ADA