Inpatient Diabetes Management Algorithm

Management Of Inpatient Hyperglycemia And Diabetes In Older Adults

Adults aged 65 years and older are the fastest growing segment of the U.S. population, and their number is expected to double to 89 million between 2010 and 2050. The prevalence of diabetes in hospitalized adults aged 65–75 years and over 80 years of age has been estimated to be 20% and 40%, respectively. Similar to general populations, the presence of hyperglycemia and diabetes in elderly patients is associated with increased risk of hospital complications, longer length of stay, and increased mortality compared with subjects with normoglycemia. Clinical guidelines recommend target blood glucose between 140 and 180 mg/dL (7.8 and 10 mmol/L) for most patients in the intensive care unit (ICU). A similar blood glucose target is recommended for patients in non-ICU settings; however, glycemic targets should be individualized in older adults on the basis of a patient’s clinical status, risk of hypoglycemia, and presence of diabetes complications. Insulin is the preferred agent to manage hyperglycemia and diabetes in the hospital. Continuous insulin infusion in the ICU and rational use of basal-bolus or basal plus supplement regimens in non-ICU settings are effective in achieving glycemic goals. Noninsulin regimens with the use of dipeptidyl peptidase 4 inhibitors alone or in combination with basal insulin have been shown to be safe and effective and may represent an alternative to basal-bolus regimens in elderly patients. Smooth transition of care to the outpatient setting is facilitated by providing oral and written instructions regarding timing and dosing of insulin as well as education in basic skills for home management. The global burden of diabetes has increased significantly during the past two decades and is expected to affect more than 642 million adults by 2040 Continue reading >>

Hospitals Work To Improve Inpatient Diabetes Management

Anwar H, et al. Diabet Med. 2011;doi:10.1111/j.1464-5491.2011.03432.x. Bersoux S, et al. Endocr Pract. 2014;doi:10.4158/EP13516.OR. Desimone ME, et al. Endocr Pract. 2012;doi:10.4158/EP11277.OR. Gibbons DC, et al. Diabet Med. 2014;doi:10.1111/dme.12444. Handelsman Y, et al. Endocr Pract. 2015;doi:0.4158/EP15672.GL. Healy SJ, et al. Diabetes Care. 2013;doi:10.2337/dc13-0108. Magee MF, et al. Diabetes Educ. 2014;40:344-350. Mathioudakis N, Golden SH. Curr Diab Rep. 2015;doi:10.1007/s11892-015-0583-8. NICE-SUGAR Study Investigators. N Engl J Med. 2012;doi:10.1056/NEJMoa1204942. Umpierrez GE, et al. Diabetes Care. 2007;30:2181-2186. Umpierrez GE, et al. Diabetes Care. 2011;doi:10.2337/dc10-1407. Umpierrez GE, et al. Diabetes Care. 2013;doi:10.2337/dc12-1988. Vaidya A, et al. Diabetes Technol Ther. 2012;doi:10.1089/dia.2011.0258. Kellie Antinori-Lent, MSN, RN, ACNS-BC, BC-ADM, CDE, can be reached at 201 Preservation Hall, 5230 Centre Ave., Pittsburgh, PA 15232; email: [email protected] . Kenneth Cusi, MD, can be reached at 1600 SW Archer Road, Room H-2, PO Box 100226, Gainesville, FL 32610; email: [email protected] . David W. Lam, MD, can be reached at 5 E. 98th St., 3rd floor, New York, NY 10029; email: [email protected] . Nestoras Mathioudakis, MD, can be reached at 601 N. Caroline St., Baltimore, MD 21287; email: [email protected] . Priyathama Vellanki, MD, can be reached at 49 Jesse Hill Drive, SE, Room 498, FOB, Atlanta, GA 30303; email: [email protected] . Antinori-Lent, Cusi, Lam, Mathioudakis and Vellanki report no relevant financial disclosures. Who should provide diabetes education to patients newly diagnosed in the hospital: The hospital staff or the primary provider? The hospital may provide a unique educational environment. Alar Continue reading >>

A Practical And Evidence-based Approach To Management Of Inpatient Diabetes In Non-critically Ill Patients And Special Clinical Populations

Highlights • Inpatient diabetes control in non-ICU patients can improve clinical outcomes. • Insulin administration is a mainstay of hyperglycemia management in the wards. • Avoidance of hypoglycemia is important during glycemia management. • Several diabetes patient groups will require different treatment approach. • Future glycemia treatment algorithms should allow individualization of therapy. Abstract Inpatient diabetes is a common medical problem encountered in up to 25–30% of hospitalized patients. Several prospective trials showed benefits of structured insulin therapy in managing inpatient hyperglycemia albeit in the expense of high hypoglycemia risk. These approaches, however, remain underutilized in hospital practice. In this review, we discuss clinical applications and limitations of current therapeutic strategies. Considerations for glycemic strategies in special clinical populations are also discussed. We suggest that given the complexity of inpatient glycemic control factors, the “one size fits all” approach should be modified to safe and less complex patient-centered evidence-based treatment strategies without compromising the treatment efficacy. Continue reading >>

A Comparison Of Inpatient Glucose Management Guidelines: Implications For Patient Safety And Quality

A Comparison of Inpatient Glucose Management Guidelines: Implications for Patient Safety and Quality Nestoras Mathioudakis and Sherita Hill Golden Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Suite 333, Baltimore, MD 21287, USA Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Suite 333, Baltimore, MD 21287, USA. Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA. Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD, USA. Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA Nestoras Mathioudakis, Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Suite 333, Baltimore, MD 21287, USA; The publisher's final edited version of this article is available at Curr Diab Rep See other articles in PMC that cite the published article. Inpatient glucose management guidelines and consensus statements play an important role in helping to keep hospitalized patients with diabetes and hyperglycemia safe and in optimizing the quality of their glycemic control. In this review article, we compare and contrast seven prominent US guidelines on recommended glycemic outcome measures and processes of care, with the goal of highlighting how variation among them might influence patient safety and quality. The outcome measures of interest include definitions of glucose abnormalities and glycemic targets. The relevant process measures include detection and documentation of diabetes/hyperglycemia, methods of and indications for insulin Continue reading >>

Hospital Guidelines

Acute Diabetic Foot Inpatient referral pathway (version 2.1 November 2017) UHL subscribes to the Royal Marsden handbook online, its an excellent resource for evidence based nursing care. Its handy if you want to know how to do anything from bed baths to cancer care (as you know, the Royal Marsden is a cancer hospital). It’s not UHL guidelines but a good second best if we don’t have local guidelines. Access via Insite only. (2014) University Hospitals of Leicester - Inpatient Guidelines The University Hospital of Leicester have produce Inpatient Guidelines for all medical teams for treatment of patients both adults and children with diabetes on the wards. These are listed below and can be downloaded by clicking on the respective titles below. Unfortunately this website is no longer being maintained as the website development post no longer exists as it is not being supported due to financial reasons by the UHL clinical team. click here . Thank You Shehnaz Jamal – diabetes website development coordinator. Polite Notice to Patients Please kindly refrain from emailing us asking for medical advice as your email will not be answered. Continue reading >>

Financial Implications Of Glycemic Control: Results Of An Inpatient Diabetes Management Program

Financial Implications of Glycemic Control: Results of an Inpatient Diabetes Management Program Financial Implications of Glycemic Control: Results of an Inpatient Diabetes Management Program To determine the financial implications associated with changes in clinical outcomes resulting from implementation of an inpatient diabetes management program. To describe the strategies involved in the formation of this program. The various factors that influence financial outcomes are examined, and previous and current outcomes are compared. Associations exist between hyperglycemia, length of stay, and hospital costs. Implementation of an inpatient diabetes management program, based on published guidelines, has been shown to increase the use of scheduled medications to treat hyperglycemia and increase the frequency of physician intervention for glucose readings outside desired ranges. Results from implementing this program have included a reduction in the average glucose level in the medical intensive care unit through use of protocols driven to initiate intravenous insulin once the glucose level exceeds 140 mg/dL. Additionally, glucose levels have been reduced throughout the hospital, primarily because of interactions between diabetes nurse care managers and the primary care team. Associated with these lower glucose levels are a decreased prevalence of central line infections and shorter lengths of stay. The reduction in the length of stay for patients with diabetes has resulted in a savings of more than $2 million for the year and has yielded a 467% return on investment for the hospital. Improved blood glucose control during the hospitalization of patients with known hyperglycemia is associated with reduced morbidity, reduced hospital length of stay, and cost savings. The impl Continue reading >>

Glycemic Control In Hospitalized Patients Not In Intensive Care: Beyond Sliding-scale Insulin

Glycemic control in hospitalized patients who are not in intensive care remains unsatisfactory. Despite persistent expert recommendations urging its abandonment, the use of sliding-scale insulin remains pervasive in U.S. hospitals. Evidence for the effectiveness of sliding-scale insulin is lacking after more than 40 years of use. New physiologic subcutaneous insulin protocols use basal, nutritional, and correctional insulin. The initial total daily dose of subcutaneous insulin is calculated using a factor of 0.3 to 0.6 units per kg body weight, with one half given as long-acting insulin (the basal insulin dose), and the other one half divided daily over three meals as short-acting insulin doses (nutritional insulin doses). A correctional insulin dose provides a final insulin adjustment based on the preprandial glucose value. This correctional dose resembles a sliding scale, but is only a small fine-tuning of therapy, as opposed to traditional sliding-scale insulin alone. Insulin sensitivity, nutritional intake, and total daily dosing review can alter the physiologic insulin-dosing schedule. Prospective trials have demonstrated reductions in hyperglycemic measurements, hypoglycemia, and adjusted hospital length of stay when physiologic subcutaneous insulin protocols are used. Transitions in care require special considerations and attention to glycemic control medications. Changing the sliding-scale insulin culture requires a multidisciplinary effort to improve patient safety and outcomes. In the United States, the prevalence of diabetes mellitus is now 10.8 percent of adults 20 years and older, and 23.1 percent of adults 60 years and older.1 An estimated one in five U.S. health care dollars is spent caring for someone with diabetes.2 Over the past 10 years, the Agency fo Continue reading >>

Management Of Diabetes Mellitus In Hospitalized Patients

INTRODUCTION Patients with type 1 or type 2 diabetes mellitus are frequently admitted to a hospital, usually for treatment of conditions other than the diabetes [1,2]. In one study, 25 percent of patients with type 1 diabetes and 30 percent with type 2 diabetes had a hospital admission during one year; patients with higher values for glycated hemoglobin (A1C) were at highest risk for admission [2]. The prevalence of diabetes rises with increasing age, as does the prevalence of other diseases; both factors increase the likelihood that an older person admitted to a hospital will have diabetes. The treatment of patients with diabetes who are admitted to the general medical wards of the hospital for a procedure or intercurrent illness is reviewed here. The treatment of hyperglycemia in critically ill patients, the perioperative management of diabetes, and the treatment of complications of the diabetes itself, such as diabetic ketoacidosis, are discussed separately. (See "Glycemic control and intensive insulin therapy in critical illness" and "Perioperative management of blood glucose in adults with diabetes mellitus" and "Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Treatment" and "Management of hypoglycemia during treatment of diabetes mellitus".) GOALS IN THE HOSPITAL SETTING The main goals in patients with diabetes needing hospitalization are to minimize disruption of the metabolic state, prevent adverse glycemic events (especially hypoglycemia), return the patient to a stable glycemic balance as quickly as possible, and ensure a smooth transition to outpatient care. These goals are not always easy to achieve. On the one hand, the stress of the acute illness tends to raise blood glucose concentrations. On the other hand, the anorexia that often a Continue reading >>

Improvement In Inpatient Glycemic Care: Pathways To Quality

Improvement in Inpatient Glycemic Care: Pathways to Quality Improvement in Inpatient Glycemic Care: Pathways to Quality Joseph Aloi, Christopher Mulla, Jagdeesh Ullal, David Lieb The management of inpatient hyperglycemia is a focus of quality improvement projects across many hospital systems while remaining a point of controversy among clinicians. The association of inpatient hyperglycemia with suboptimal hospital outcomes is accepted by clinical care teams; however, the clear benefits of targeting hyperglycemia as a mechanism to improve hospital outcomes remain contentious. Glycemic management is also frequently confused with efforts aimed at intensive glucose control, further adding to the confusion. Nonetheless, several regulatory agencies assign quality rankings based on attaining specified glycemic targets for selected groups of patients (Surgical Care Improvement Project (SCIP) measures). The current paper reviews the data supporting the benefits associated with inpatient glycemic control projects, the components of a successful glycemic control intervention, and utilization of the electronic medical record in implementing an inpatient glycemic control project. Efforts at improving the efficiency and outcomes of inpatient care have gained increased scrutiny and the development of policies targeting specific patient groups. Inpatient hyperglycemia is a common event with an event rate of approximately 40% of all hospitalizations and has gained particular attention as a quality metric [1]. Hyperglycemia is a common occurrence in patients with a known diagnosis of diabetes prior to an admission but is also a frequent event in patients without a prior diagnosis of diabetes. Inpatient hyperglycemia in particular hyperglycemia in the non-diabetic patient predicts poor o Continue reading >>

Inpatient Hyperglycemia Management: The Opportunities Of A New Basal Insulin

Background In the last years there have been many efforts to find the most suitable management of the diabetic inpatient so to reduce hyperglycemia and hypoglycemia, glycemic variability and length of stay as well. In fact, the research Management of insulin therapy in hospital in PubMed (on date 10/25/2015) generates more than 3000 results, of which 989 reviews, 489 Clinical Trials and 28 guidelines. Approximately, 38-46% of non-Intensive Care Unit (ICU) hospitalized patients have diabetes mellitus, either with or without a prior diagnosis. Hyperglycemia is generally associated with an increased risk of mortality, complications and lengths of stays. The mortality rate of in-patients with an hyperglycemia of new diagnosis (16%) or with an history of diabetes (3%) is higher than hospitalized patients with normoglycemia (1.7%; both P<0.01).1 In hospitalized patients not only hyperglycemia, but also hypoglycemia is associated with an increased risk of mortality, length of stay and complications. The incidence of hypoglycemia (defined as blood glucose levels ≤70 mg/dL) in patients admitted to general medical wards is between 3.5% and 10.5. In patients with diabetes, hypoglycemia can occur in 12%-18%, with even higher rates reported when more aggressive antihyperglycemic therapy is used.2 Examination of the hourly distribution showed that the majority of hypoglycemic events appeared to occur overnight. This distribution is similar in hypoglycemia spontaneous or associated with antihyperglycemic therapy.3-5 Risk factors for nocturnal hypoglycemia include the reduced caloric intake, interruptions in enteral nutrition for scheduled procedures, decreased bedside visits by nursing staff with delayed recognition of hypoglycemic signs and symptoms, and impaired counter-regulatory Continue reading >>

Synopsis Of The 2017 U.s. Department Of Veterans Affairs/u.s. Department Of Defense Clinical Practice Guideline: Management Of Type 2 Diabetes Mellitus Free

Abstract Description: In April 2017, the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DoD) approved a joint clinical practice guideline for the management of type 2 diabetes mellitus. Methods: The VA/DoD Evidence-Based Practice Work Group convened a joint VA/DoD guideline development effort that included a multidisciplinary panel of practicing clinician stakeholders and conformed to the Institute of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel developed key questions in collaboration with the ECRI Institute, which systematically searched and evaluated the literature through June 2016, developed an algorithm, and rated recommendations by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. Recommendations: This synopsis summarizes key features of the guideline in 7 areas: patient-centered care and shared decision making, glycemic biomarkers, hemoglobin A1c target ranges, individualized treatment plans, outpatient pharmacologic treatment, glucose targets for critically ill patients, and treatment of hospitalized patients. Diabetes is the leading cause of major complications, such as end-stage renal disease and lower extremity amputations, and is a significant contributor to ischemic heart disease, stroke, peripheral vascular disease, and vision loss (1). There has been increasing acceptance of the importance of individualizing glycemic management and assessment of risk for adverse events, especially hypoglycemia (2–6). This is of great importance for all patients, especially older adults (aged ≥65 years) with comorbid conditions. In 2013, 12.0 million older adults in the United States had diabetes, comprising 40% of the 30.2 million persons with the disease (7 Continue reading >>

13. Diabetes Care In The Hospital

Consider performing an A1C on all patients with diabetes or hyperglycemia admitted to the hospital if not performed in the prior 3 months. 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 140–180 mg/dL (7.8–10.0 mmol/L) is recommended for the majority of critically ill patients A and noncritically ill patients. C More stringent goals, such as 110–140 mg/dL (6.1–7.8 mmol/L) may be appropriate for selected critically ill patients, as long as this can be achieved without significant hypoglycemia. C Intravenous insulin infusions should be administered using validated written or computerized protocols that allow for predefined adjustments in the insulin infusion rate based on glycemic fluctuations and insulin dose. E 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 components is the preferred treatment for patients with good nutritional intake. A The sole use of sliding scale insulin in the inpatient hospital setting is strongly discouraged. A A hypoglycemia management protocol should be adopted and implemented by each hospital or hospital system. A plan for preventing and treating hypoglycemia should be established for each patient. Episodes of hypoglycemia in the hospital should be documented in the medical record and tracked. E 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 There should be a structured discharge plan tailored to the individual p Continue reading >>

Improving Inpatient Glycemic Control | Journal Of Hospital Medicine

Diagnostic and treatment algorithm for sleep in hospitalized medical patients. In this beforeafter study, we found that a multifaceted intervention consisting of a subcutaneous insulin protocol, focused education, and an order set built into the hospital's CPOE system was associated with a significantly higher percentage of glucose readings within range per patient in analyses adjusted for patient demographics and severity of diabetes. We also found a significant decrease in patientday weighted mean glucose, a marked increase in appropriate use of scheduled nutritional insulin, and a concomitant decrease in sliding scale insulin only regimens during the postintervention period. Moreover, we found a shorter length of stay during the postintervention period that persisted after adjustment for several clinical factors. Importantly, the interventions described in this study require very few resources to continue indefinitely: printing costs for the management protocol, 4 hours of education delivered per year, and routine upkeep of an electronic order set. Because this was a beforeafter study, we cannot exclude the possibility that these improvements in process and outcome were due to cointerventions and/or temporal trends. However, we know of no other interventions aimed at improving diabetes care in this selfcontained service of nurses, PAs, and hospitalists. Moreover, the process improvements, especially the increase in scheduled nutritional insulin, were rather marked, unlikely to be due to temporal trends alone, and likely capable of producing the corresponding improvements in glucose control. That glucose control stopped improving after hospital day 3 may be due to the fact that subsequent adjustment to insulin orders occurred infrequently and no more often than prior Continue reading >>

Management Of Inpatient Hyperglycemia

Case Vignette 45 year old obese female with DM type II is admitted for acute nausea, vomiting, and epigastric pain. CT Abdomen with IV contrast demonstrates acute pancreatitis. Her diabetes is usually controlled on metformin 1000mg BID and glyburide 10mg BID. Admission BMP shows a random glucose of 240. How do you manage her hyperglycemia? A. Continue home regimen Continue home glyburide and discontinue metformin Start sliding scale insulin Start correction insulin * No need to answer, weâ€™ll come back to this at the end Learning Objectives Appreciate difference between sliding scale insulin vs correction insulin Understand optimal glycemic control goals in ICU vs non ICU settings Review the pharmacokinetics of different insulin preparations Learn how to use correction insulin and initiate insulin therapy on UCI wards The problem with sliding scale insulin Sliding Scale Insulin - Treats hyperglycemia with only short/rapid acting insulin without long-acting basal insulin Reactive therapy Treats current hyperglycemia, does not prevent future hyperglycemia Can cause large swings in glucose levels throughout day Typical day battling hyperglycemia Time 0700 Break- fast 0800 1200 Lunch 1300 1700 Dinner 1800 2100 Blood Glucose 275 350 400 250 Sliding scale 6 units 10 units 12 units 6 units Chart Explanation: Prior to breakfast, a pre-prandial BS is found to be 275 so got 6 units, etc. Problem with sliding scale is that it is reactive and does not prevent hyperglycemia from occuring. Usually used without long acting insulin. Studies have shown that when sliding scale is used in conjunction with long acting insulin, there are more episodes of hyperglycemia. Correction Insulin Correctional Insulin Results in physiologic subcutaneous insulin administration Treats current hyp Continue reading >>

Inpatient Diabetes Management Service

Director, Inpatient Diabetes Management Service Associate Director, Inpatient Diabetes Management Service Nurse Practitioner, Inpatient Diabetes Management Service Clinical Facilitator, Glucose Steering Committee Nurse Practitioner, Inpatient Diabetes Management Service The Johns Hopkins Inpatient Diabetes Management Service (IDMS) was implemented on July 1, 2003, as a pilot diabetes clinical consultation service to improve glucose control and reduce length of stay in people with diabetes undergoing cardiac surgery.During the first year of the program, the length of stay for people with diabetes undergoing cardiac surgery was reduced by 58 percent.We subsequently expanded to other clinical services throughout the hospital. In January 2006, our clinical service became an integral component to a hospital-wide Glucose Control Task Force (GCTF) that was commissioned in response to a sentinel event related to hypoglycemia.Because of ongoing need for diabetes policy development, education and safety monitoring, the GCTF evolved into a standing Glucose Management Committee (GMC) in July 2008 and into the Glucose Steering Committee in July 2010. View the Structure and Composition of the Inpatient Diabetes Management Program Together, the IDMS and Glucose Steering Committee comprise the Johns Hopkins Glucose Management Program. The goals of this program are as follows: To perform inpatient diabetes consultations and respond promptly and effectively to improve glycemic control among inpatients with diabetes on adult medical and surgical services.Our clinical services are currently focused on several complex patient populations that require our support: cardiac surgery, transplant surgery, pancreatectomy and insulin pump patients. To expand the inpatient diabetes management servi Continue reading >>