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 >>
Inpatient Diabetes Management
The Diabetes, Obesity, and Nutrition Strategic Clinical Network (DON SCN) is leading a provincial initiative: with the goal of improving and standardizing how patients with diabetes are cared for in Albertas hospitals. This is a multipronged quality improvement initiative, in collaboration with AHS provincial Pharmacy, AHS provincial Nutrition and Food Services, and the Zone operational areas. It involves a multidisciplinary approach (with many different health care providers) to diabetes management, with the patient and family as key team members. 1 in 5 adult patients admitted to hospital in Alberta has diabetes. When compared to their non-diabetic counterparts, patients with diabetes have longer hospital stays. Provincially, the average length of stay among patients with diabetes was 5 days, which is two days longer than the average length of stay among non-diabetics. The inpatient diabetes management initiative is a priority for the DON SCN because hyperglycemia continues to be common in hospitals and increases the risk of complications including: post-operative infections, pneumonia, diabetic ketoacidosis (DKA), and delays wound healing. Literature suggests that patients with diabetes experience hyperglycemia (high blood sugar) 38 per cent of the time they are in hospital. Alberta data is consistent with this figure. Improving blood sugar control in hospital has been associated with shorter length of stay in hospital and decreased rates of readmission. National Guidelines recommend blood glucose targets of 5-10 mmol/L for most patients with diabetes in hospital. Blood glucose targets of 5-12 mmol/L are recommended in the frail elderly, those with limited life expectancy and those at risk for severe hypoglycemia (e.g. hypoglycemia unawareness). See more information Continue reading >>
Diabetes Management Guidelines
Source: American Diabetes Association. Standards of medical care in diabetes—2016. Diabetes Care. 2016;39(suppl 1):S1-S106. Available here. Refer to source document for full recommendations, including class of recommendation and level of evidence. Jump to a topic or click back/next at the bottom of each page In-Patient Glycemia Diabetes Care in the Hospital Insulin is preferred method for glycemic control in the hospital setting Exclusive use of SSI is strongly discouraged Recommendations for diabetes care of patients in the ICU (critical care): Intravenous insulin shown to be the best method for achieving glycemic targets Administer using validated written or computerized protocols that allow for predefined adjustments in infusion rate based on glycemic fluctuations and insulin dose Recommendations for diabetes care of patients in noncritical care settings: Scheduled subcutaneous insulin injections that align with meals and bedtime* Insulin regimen with basal, nutritional, and correction components (basal-bolus) for individuals with good nutritional intake Basal plus correction insulin regimen for individuals with poor oral intake or who are NPO The safety and efficacy of noninsulin therapies are being studied *Or every 4-6 hrs if no meals or if continuous enteral/parenteral therapy being used Glycemic Targets for Critically Ill Individuals Insulin is the preferred method for achieving glycemic control for diabetes care in the hospital Recommendations for critically ill individuals with persistent hyperglycemia: Initiate insulin starting at ≤180 mg/dL (10.0 mmol/L) Once insulin is started, a target glucose range of 140-180 mg/dL (7.8-10.0 mmol/L) is recommended for most patients More stringent targets may be appropriate for certain patients providing a lower target 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 >>
Protocols And Order Sets
The order sets provided here are only a few examples from institutions involved in the management of inpatient hyperglycemia; this is not an all-inclusive list. Posting of these protocols does not constitute endorsement of any specific protocol. We believe that each institution should consult with diabetes experts to select and implement insulin protocols. Key Points Successful implementation of protocols requires: Buy-in from key stakeholders (critical care physicians, house staff, nursing, pharmacy, hospital administration, etc) Appropriate education through in-servicing of hospital staff Ongoing monitoring of results Support from endocrinologists for specific questions or when a patient does not respond to the protocol as expected It is important to keep in mind that these algorithms have not been directly compared in clinical trials. In selecting a protocol, one should look for characteristics that are compatible with the institution in which it will be implemented. Consideration should be given to the following characteristics and whether these attributes will fit within the institution: Is the protocol dynamic (ie, does it allow for variability in insulin requirements and account for rates of change in blood glucose concentrations)? What is its relative user-friendliness and complexity? To what extent does it require performance of basic calculations? Is it compatible with the local computer systems? None of the examples provided are suitable for the treatment of diabetic ketoacidosis. 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 >>
- NIHR Signal Insulin pumps not much better than multiple injections for intensive control of type 1 diabetes
- The effect of a low-carbohydrate, ketogenic diet versus a low-glycemic index diet on glycemic control in type 2 diabetes mellitus
- Relative effectiveness of insulin pump treatment over multiple daily injections and structured education during flexible intensive insulin treatment for type 1 diabetes: cluster randomised trial (REPOSE)
The Impact Of Introducing Inpatient Diabetes Management Protocol On Glycemic Control In A Rural Secondary Care Hospital In The Uae | Khthir | Journal Of Endocrinology And Diabetes Mellitus
Journal of Endocrinology and Diabetes Mellitus Subscription Login to verify subscription The Impact of Introducing Inpatient Diabetes Management Protocol on Glycemic Control in a Rural Secondary Care Hospital in the UAE Rodhan Khthir, Ibrahim Hatab, Blessy Rajan, Felyn Luz Espina Background: Diabetes is one of the most common diagnoses encountered in hospitalized patients. In-hospital hyperglycemia is considered an independent marker of in-hospital poor outcome even in those without prior diagnosis of Diabetes. The purpose of this study is to evaluate the impact of introducing inpatient diabetes management protocol at Madinat Zayed hospital, a rural secondary care hospital in the Western region of Abu Dhabi, UAE. Methods: Adult, non-pregnant Patients admitted to the hospital with diabetes or a blood glucose >7.8 mmol/l (140 mg/dl) were included. The protocol guided physicians to start weight based insulin regimen for all patients with type 1diabetes, insulin dependent type 2 diabetes and all hyperglycemic patients regardless of history of diabetes. All patients who required insulin therapy were treated with basal and bolus insulin. A historical control was randomly selected for comparison. Results: 101 patients were identified in the intervention group and 69 patients in the historical control group. The mean glucose level in the treatment group was 9.2 3.1 mmol/l (165.6 55.8 mg/dl) and 12.4 2.7 mmol/l (22348.6 mg/dl) in the historical control group with a reduction of 26% in the mean glucose level (P<0.05). Patients with episodes of sever hyperglycemia (glucose level >16.6 mmol/l or 300 mg/dl) was significantly lower in the interventional group (23% versus 66%) with p value <0.001). There was no significant difference in the rate of hypoglycemia, length of hospital st 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 >>
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 >>
Role Of The Diabetes Educator
2016 American Association of Diabetes Educators, Chicago, IL 1 Role of the Diabetes Educator in Inpatient Diabetes Management August 2016 Diabetes educators are a valuable asset to the interdisciplinary team and are uniquely prepared to facilitate change and implement processes and programs to improve glycemic control.19, 20 Diabetes educators play a key leadership role in creating or implementing:  interdisciplinary teams (related to quality improvement, patient or medication safety, documentation/tool development, clinical informatics & decision support)  comprehensive staff diabetes education  the collection of blood glucose data and the surveillance of outcome measurements  evidence-based hypoglycemia and hyperglycemia management order sets and protocols (as well as monitoring, tracking, and root cause analysis to prevent errors and patient harm)  individualized medication management plans within the hospital setting and for use after discharge, and  a plan of care that facilitates a smooth transition across the care settings  The diabetes educator’s responsibility as a leader or member of the interdisciplinary team includes input into patient education, identifying barriers to care, care coordination and transition, nutrition therapy, medication therapy and management, hypoglycemia management and prevention, monitoring glycemic control, and professional education.19, 21-23 All components of hospital care that affect inpatient glycemia need to be considered in initiatives to improve inpatient care.12, 17, 24-27 Diabetes mellitus is the second most common diagnosis for those discharged from hospitals among adults age 18 and older.1 Patients with diabetes are frequently hospitalized, for treatment of conditions o Continue reading >>
Quality Of Inpatient Diabetes Management | Journal Of Hospital Medicine
Hospitalistrun general medicine service of an academic teaching hospital. 107 consecutive patients with diabetes mellitus or inpatient hyperglycemia. We collected data on up to 4 bedside glucose measurements per day, detailed clinical information, and all orders related to glucose management. The primary outcomes were rate of hyperglycemia (glucose > 180 mg/dL) per patient and mean glucose level per patientday. The mean rate of hyperglycemia was 31% of measurements per patient. Basal insulin was ordered for 43% of patients, and scheduled rapid or shortacting insulin was ordered for 4% of patients. Sixtyfive percent of patients who had at least 1 episode of hyper or hypoglycemia had no change made to any insulin order during the first 5 days of the hospitalization. When adjusted for clinical factors, the use of slidingscale insulin by itself was associated with a 20 mg/dL higher mean glucose level per patientday. Management of diabetes and hyperglycemia on a general medicine service showed several deficiencies in process and outcome. Possible targets for improvement include increased use of basal and nutritional insulin and daily insulin adjustment in response to hyperglycemia. Journal of Hospital Medicine 2006;3:145150. 2006 Society of Hospital Medicine. Copyright 2006 Society of Hospital Medicine Diabetes mellitus is a common comorbidity of hospitalization; in 2003 diabetes was a secondary diagnosis in 17.8% of all adult hospital discharges. 1 When undiagnosed diabetes is included, the prevalence of inpatient diabetes or hyperglycemia may be as high as 38%. 2 Recent studies show that hyperglycemia in hospitalized patients complicates numerous illnesses and is an independent predictor of adverse outcomes. 3 Treatment of inpatient hyperglycemia improves outcomes, includ 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 >>
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 >>
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 >>
Management Of Inpatient Hyperglycemia
1. Management of InpatientManagement of Inpatient HyperglycemiaHyperglycemia By- Dr. Armaan SinghBy- Dr. Armaan Singh 2. Case VignetteCase 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 B. Continue home glyburide and discontinue metformin C. Start sliding scale insulin D. Start correction insulin 3. Learning ObjectivesLearning 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 4. The problem with sliding scale insulinThe problem with sliding scale insulin 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 •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 5. Correction InsulinCorrection Insulin • Correctional Insulin o Results in physiologic subcutaneous insulin administration o Treats current hyperglycemia with the goal of preventing further hyperglycemic events during the hospital course o Includes initiation of three components: 1. basal insulin (long acting) 2. nutri Continue reading >>
