DIABETES CARE IN THE HOSPITAL: STANDARDSOFMEDICALCAREIN DIABETESD2021 - FLORIDA DIABETES ALLIANCE
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Diabetes Care Volume 44, Supplement 1, January 2021 S211
15. Diabetes Care in the Hospital: American Diabetes Association
Standards of Medical Care in
Diabetesd2021
Diabetes Care 2021;44(Suppl. 1):S211–S220 | https://doi.org/10.2337/dc21-s015
The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes”
15. DIABETES CARE IN THE HOSPITAL
includes the ADA’s current clinical practice recommendations and is intended to
provide the components of diabetes care, general treatment goals and guidelines,
and tools to evaluate quality of care. Members of the ADA Professional Practice
Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-
SPPC), are responsible for updating the Standards of Care annually, or more
frequently as warranted. For a detailed description of ADA standards, statements,
and reports, as well as the evidence-grading system for ADA’s clinical practice
recommendations, please refer to the Standards of Care Introduction (https://doi
.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care
are invited to do so at professional.diabetes.org/SOC.
Among hospitalized patients, hyperglycemia, hypoglycemia, and glucose variability
are associated with adverse outcomes, including death (1–3). Therefore, careful
management of inpatients with diabetes has direct and immediate benefits. Hospital
management of diabetes is facilitated by preadmission treatment of hyperglycemia in
patients having elective procedures, a dedicated inpatient diabetes service applying
well-developed standards, and careful transition out of the hospital to prearranged
outpatient management. These steps can shorten hospital stays and reduce the need
for readmission as well as improve patient outcomes. Some in-depth reviews of
hospital care for patients with diabetes have been published (3–5). For older
hospitalized patients or for patients in the long-term care facilities, please see
Section 12 “Older Adults” (https://doi.org/10.2337/dc21-S012).
HOSPITAL CARE DELIVERY STANDARDS
Recommendations
15.1 Perform an A1C test on all patients with diabetes or hyperglycemia (blood
glucose .140 mg/dL [7.8 mmol/L]) admitted to the hospital if not performed
in the prior 3 months. B
15.2 Insulin should be administered using validated written or computerized
protocols that allow for predefined adjustments in the insulin dosage based Suggested citation: American Diabetes Associa-
tion. 15. Diabetes care in the hospital: Standards
on glycemic fluctuations. B of Medical Care in Diabetesd2021. Diabetes
Care 44 (Suppl. 1):S211–S220
Considerations on Admission © 2020 by the American Diabetes Association.
High-quality hospital care for diabetes requires standards for care delivery, which are Readers may use this article as long as the work is
properly cited, the use is educational and not for
best implemented using structured order sets, and quality assurance for process profit, and the work is not altered. More infor-
improvement. Unfortunately, “best practice” protocols, reviews, and guidelines (2–4) mation is available at https://www.diabetesjournals
are inconsistently implemented within hospitals. To correct this, medical centers .org/content/license.S212 Diabetes Care in the Hospital Diabetes Care Volume 44, Supplement 1, January 2021
striving for optimal inpatient diabetes Appropriately trained specialists or spe- changes to medications that cause hyper-
treatment should establish protocols cialty teams may reduce length of stay, glycemia. An admission A1C value $6.5%
and structured order sets, which in- improve glycemic control, and improve (48 mmol/mol) suggests that the onset
clude computerized physician order outcomes (10,18,19). In addition, the of diabetes preceded hospitalization
entry (CPOE). greater risk of 30-day readmission fol- (see Section 2 “Classification and Di-
Initial orders should state the type of lowing hospitalization that has been at- agnosis of Diabetes,” https://doi.org/
diabetes (i.e., type 1, type 2, gestational tributed to diabetes can be reduced, and 10.2337/dc21-S002) (2,25). Hypoglyce-
diabetes mellitus, pancreatic diabetes) costs saved, when inpatient care is pro- mia in hospitalized patients is catego-
when it is known. Because inpatient vided by a specialized diabetes manage- rized by blood glucose concentration
treatment and discharge planning are ment team (20,21). In a cross-sectional and clinical correlates (Table 6.4) (26):
more effective if based on preadmission comparison of usual care to management Level 1 hypoglycemia is a glucose con-
glycemia, an A1C should be measured for by specialists who reviewed cases and centration 54–70 mg/dL (3.0–3.9 mmol/L).
all patients with diabetes or hyperglyce- made recommendations solely through Level 2 hypoglycemia is a blood glucose
mia admitted to the hospital if the test the electronic medical record, rates of concentration ,54 mg/dL (3.0 mmol/L),
has not been performed in the previous both hyper- and hypoglycemia were re- which is typically the threshold for neu-
3 months (6–9). In addition, diabetes duced 30–40% by electronic “virtual roglycopenic symptoms. Level 3 hypogly-
self-management knowledge and behav- care” (22). Details of team formation cemia is a clinical event characterized by
iors should be assessed on admission are available in The Joint Commission altered mental and/or physical function-
and diabetes self-management educa- Standards for programs and from the ing that requires assistance from another
tion provided, if appropriate. Diabetes Society of Hospital Medicine (23,24). person for recovery. Levels 2 and 3 re-
self-management education should in- Even the best orders may not be quire immediate correction of low blood
clude appropriate skills needed after carried out in a way that improves qual- glucose.
discharge, such as medication dosing ity, nor are they automatically updated
and administration, glucose monitor- when new evidence arises. To this end, Glycemic Targets
ing, and recognition and treatment of the Joint Commission has an accredita- In a landmark clinical trial, Van den
hypoglycemia (2,3). There is evidence tion program for the hospital care of Berghe et al. (27) demonstrated that
to support preadmission treatment of diabetes (23), and the Society of Hospital an intensive intravenous insulin regimen
hyperglycemia in patients scheduled Medicine has a workbook for program to reach a target glycemic range of 80–
for elective surgery as an effective development (24). 110 mg/dL (4.4–6.1 mmol/L) reduced
means of reducing adverse outcomes mortality by 40% compared with a stan-
(10–13). dard approach targeting blood glucose of
GLYCEMIC TARGETS IN
The National Academy of Medicine HOSPITALIZED PATIENTS 180–215 mg/dL (10–12 mmol/L) in crit-
recommends CPOE to prevent medication- ically ill patients with recent surgery. This
related errors and to increase efficiency Recommendations study provided robust evidence that
in medication administration (14). A Co- 15.4 Insulin therapy should be initi- active treatment to lower blood glucose
chrane review of randomized controlled ated for treatment of persis- in hospitalized patients had immediate
trials using computerized advice to im- tent hyperglycemia starting benefits. However, a large, multicenter
prove glucose control in the hospital at a threshold $180 mg/dL follow-up study, the Normoglycemia in
found significant improvement in the (10.0 mmol/L). Once insulin Intensive Care Evaluation and Survival
percentage of time patients spent in therapy is started, a target glu- Using Glucose Algorithm Regulation
the target glucose range, lower mean cose range of 140–180 mg/dL (NICE-SUGAR) trial (28), led to a recon-
blood glucose levels, and no increase in (7.8–10.0 mmol/L) is recom- sideration of the optimal target range for
hypoglycemia (15). Thus, where feasible, mended for the majority of glucose lowering in critical illness. In this
there should be structured order sets critically ill and noncritically trial, critically ill patients randomized to
that provide computerized advice for ill patients. A intensive glycemic control (80–110 mg/
glucose control. Electronic insulin order 15.5 More stringent goals, such as dL) derived no significant treatment ad-
templates also improve mean glucose 110–140 mg/dL (6.1–7.8 mmol/ vantage compared with a group with
levels without increasing hypoglycemia L), may be appropriate for se- more moderate glycemic targets (140–
in patients with type 2 diabetes, so lected patients if they can be 180 mg/dL [7.8–10.0 mmol/L]) and in fact
structured insulin order sets should be achieved without significant hy- had slightly but significantly higher mor-
incorporated into the CPOE (16,17). poglycemia. C tality (27.5% vs. 25%). The intensively
treated group had 10- to 15-fold greater
Diabetes Care Providers in the Hospital Standard Definitions of Glucose rates of hypoglycemia, which may have
Abnormalities contributed to the adverse outcomes
Recommendation
Hyperglycemia in hospitalized patients is noted. The findings from NICE-SUGAR
15.3 When caring for hospitalized
defined as blood glucose levels .140 mg/ are supported by several meta-analyses,
patients with diabetes, consult
dL (7.8 mmol/L) (2,3,25). Blood glucose some of which suggest that tight glyce-
with a specialized diabetes or glu-
levels persistently above this level mic control increases mortality com-
cose management team when
should prompt conservative interven- pared with more moderate glycemic
possible. C
tions, such as alterations in diet or targets and generally causes higher ratescare.diabetesjournals.org Diabetes Care in the Hospital S213
of hypoglycemia (29–31). Based on taken from fingersticks, similar to the GLUCOSE-LOWERING TREATMENT
these results, insulin therapy should process used by outpatients for home IN HOSPITALIZED PATIENTS
be initiated for treatment of persistent glucose monitoring (36). Point-of-care Recommendations
hyperglycemia $180 mg/dL (10.0 mmol/L) (POC) meters are not as accurate or as 15.6 Basal insulin or a basal plus bolus
and targeted to a glucose range of 140– precise as laboratory glucose analyzers, correction insulin regimen is the
180 mg/dL (7.8–10.0 mmol/L) for the and capillary blood glucose readings are preferred treatment for noncriti-
majority of critically ill patients. Although subject to artifact due to perfusion, cally ill hospitalized patients with
not as well supported by data from ran- edema, anemia/erythrocytosis, and sev- poor oral intake or those who are
domized controlled trials, these recom- eral medications commonly used in the taking nothing by mouth. A
mendations have been extended to hospital (37). The U.S. Food and Drug 15.7 An insulin regimen with basal,
hospitalized patients without critical ill- Administration (FDA) has established prandial, and correction compo-
ness. More stringent goals, such as 110– standards for capillary (fingerstick) blood nents is the preferred treatment
140 mg/dL (6.1–7.8 mmol/L), may be glucose meters used in the ambulatory for noncritically ill hospitalized
appropriate for selected patients (e.g., setting as well as standards to be applied patients with good nutritional
critically ill postsurgical patients or patients for POC measures in the hospital (37). intake. A
with cardiac surgery), as long as they can be The balance between analytic require- 15.8 Use of only a sliding scale insulin
achieved without significant hypoglycemia ments (e.g., accuracy, precision, interfer- regimen in the inpatient hospital
(32,33). On the other hand, glucose con- ence) and clinical requirements (rapidity, setting is strongly discouraged. A
centrations between 180 mg/dL and simplicity, point of care) has not been
250 mg/dL (10–13.9 mmol/L) may be uniformly resolved (36,38), and most
Insulin Therapy
acceptable in patients with severe comor- hospitals/medical centers have arrived
Critical Care Setting
bidities, and in inpatient care settings at their own policies to balance these
where frequent glucose monitoring or parameters. It is critically important In the critical care setting, continuous
close nursing supervision is not feasible. that devices selected for in-hospital intravenous insulin infusion is the most
Glycemic levels above 250 mg/dL use, and the workflow through which effective method for achieving glycemic
(13.9 mmol/L) may be acceptable in ter- they are applied, have careful analysis targets. Intravenous insulin infusions
minally ill patients with short life expec- of performance and reliability and on- should be administered based on vali-
tancy. In these patients, less aggressive going quality assessments. Recent dated written or computerized protocols
insulin regimens to minimize glucosu- studies indicate that POC measures that allow for predefined adjustments in
ria, dehydration, and electrolyte dis- provide adequate information for usual the infusion rate, accounting for glycemic
turbances are often more appropriate. practice, with only rare instances fluctuations and insulin dose (3).
Clinical judgment combined with on- where care has been compromised Noncritical Care Setting
going assessment of clinical status, in- (39,40). Good practice dictates that In most instances, insulin is the preferred
cluding changes in the trajectory of any glucose result that does not cor- treatment for hyperglycemia in hospi-
glucose measures, illness severity, nu- relate with the patient’s clinical status talized patients. However, in certain cir-
tritional status, or concomitant medi- should be confirmed through measure- cumstances, it may be appropriate to
cations that might affect glucose levels ment of a serum sample in the clinical continue home regimens including oral
(e.g., glucocorticoids), should be incor- laboratory. glucose-lowering medications (41). If oral
porated into the day-to-day decisions medications are held in the hospital,
regarding insulin dosing (34). Continuous Glucose Monitoring there should be a protocol for resuming
Real-time continuous glucose monitor- them 1–2 days before discharge. For
ing (CGM) provides frequent measure- patients using insulin, recent reports in-
BEDSIDE BLOOD GLUCOSE ments of interstitial glucose levels as well dicate that inpatient use of insulin pens is
MONITORING as direction and magnitude of glucose safe and may be associated with im-
In hospitalized patients with diabetes trends. Even though CGM has theoret- proved nurse satisfaction compared
who are eating, bedside glucose moni- ical advantages over POC glucose with the use of insulin vials and syringes
toring should be performed before testing in detecting and reducing the (42–44). Insulin pens have been the sub-
meals; in those not eating, glucose mon- incidence of hypoglycemia, it has not ject of an FDA warning because of po-
itoring is advised every 4–6 h (2). More been approved by the FDA for inpatient tential blood-borne diseases; the
frequent bedside blood glucose testing use. Some hospitals with established warning “For single patient use only”
ranging from every 30 min to every 2 h is glucose management teams allow the should be rigorously followed (45).
the required standard for safe use of use of CGM in selected patients on an Outside of critical care units, sched-
intravenous insulin. Safety standards for individual basis, provided both the uled insulin regimens are recommended
blood glucose monitoring that prohibit patients and the glucose management to manage hyperglycemia in patients
the sharing of lancets, other testing team are well educated in the use of with diabetes. Regimens using insulin
materials, and needles are mandatory this technology. CGM is not approved analogs and human insulin result in
(35). for intensive care unit use. For more similar glycemic control in the hospital
The vast majority of hospital glucose information on CGM, see Section 7 setting (46). The use of subcutaneous
monitoring is performed using standard “Diabetes Technology” (https://doi.org/ rapid- or short-acting insulin before meals,
glucose monitors and capillary blood 10.2337/dc21-S007). or every 4–6 h if no meals are given or ifS214 Diabetes Care in the Hospital Diabetes Care Volume 44, Supplement 1, January 2021
the patient is receiving continuous enteral/ is eating. Most importantly, patients with
hypoglycemia should be estab-
parenteral nutrition, is indicated to cor- type 1 diabetes should always be treated
lished for each patient. Episodes
rect hyperglycemia. Basal insulin, or a with insulin.
of hypoglycemia in the hospital
basal plus bolus correction regimen, is Transitioning Intravenous to Subcutaneous should be documented in the
the preferred treatment for noncritically Insulin medical record and tracked. E
ill hospitalized patients with poor oral When discontinuing intravenous insulin, 15.10 The treatment regimen should
intake or those who are restricted from a transition protocol is associated with be reviewed and changed as
oral intake. An insulin regimen with basal, less morbidity and lower costs of care necessary to prevent further
prandial, and correction components is (53,54) and is therefore recommended. hypoglycemia when a blood
the preferred treatment for noncritically A patient with type 1 or type 2 diabetes glucose value of ,70 mg/dL
ill hospitalized patients with good nutri- being transitioned to a subcutaneous (3.9 mmol/L) is documented. C
tional intake. regimen should receive a dose of sub-
For patients who are eating, insulin cutaneous basal insulin 2 h before the Patients with or without diabetes may
injections should align with meals. In intravenous infusion is discontinued. The experience hypoglycemia in the hospital
such instances, POC glucose testing should dose of basal insulin is best calculated on setting. While hypoglycemia is associ-
be performed immediately before meals. If the basis of the insulin infusion rate ated with increased mortality (64), in
oral intake is poor, a safer procedure is to during the last 6 h when stable glycemic many cases it is a marker of underlying
administer prandial insulin immediately goals were achieved (55). For patients disease rather than the cause of fatality.
after the patient eats, with the dose ad- transitioning to regimens with concen- However, hypoglycemia is a severe con-
justed to be appropriate for the amount trated insulin (U-200, U-300, or U-500) in sequence of dysregulated metabolism
ingested (46). the inpatient setting, it is important to and/or diabetes treatment, and it is
A randomized controlled trial has ensure correct dosing by utilizing an imperative that it be minimized in hos-
shown that basal-bolus treatment im- individual pen and cartridge for each pitalized patients. Many episodes of
proved glycemic control and reduced patient and by meticulous supervision hypoglycemia among inpatients are
hospital complications compared with of the dose administered (55,56). preventable. Therefore, a hypoglyce-
reactive, or sliding scale, insulin regimens
mia prevention and management pro-
(i.e., dosing given in response to elevated Noninsulin Therapies tocol should be adopted and implemented
glucose rather than preemptively) in The safety and efficacy of noninsulin by each hospital or hospital system. A
general surgery patients with type 2 di- glucose-lowering therapies in the hospi- standardized hospital-wide, nurse-initiated
abetes (47). Prolonged use of sliding scale tal setting is an area of active research hypoglycemia treatment protocol should
insulin regimens as the sole treatment of (57,58). Several recent randomized trials be in place to immediately address blood
hyperglycemic inpatients is strongly dis- have demonstrated the potential effec- glucose levels of ,70 mg/dL (3.9 mmol/L).
couraged (19,48). tiveness of glucagon-like peptide 1 recep- In addition, individualized plans for pre-
While there is evidence for using pre- tor agonists and dipeptidyl peptidase venting and treating hypoglycemia for each
mixed insulin formulations in the out- 4 inhibitors in specific groups of hospi- patient should also be developed. An
patient setting (49), a recent inpatient talized patients (59–62). However, an American Diabetes Association (ADA) con-
study of 70/30 NPH/regular insulin ver- FDA bulletin states that providers should sensus statement recommends that a pa-
sus basal-bolus therapy showed compa- consider discontinuing saxagliptin and tient’s treatment regimen be reviewed any
rable glycemic control but significantly alogliptin in people who develop heart time a blood glucose value of ,70 mg/dL
increased hypoglycemia in the group failure (63). (3.9 mmol/L) occurs, as such readings often
receiving premixed insulin (50). There- Sodium–glucose cotransporter 2 (SGLT2) predict subsequent level 3 hypoglycemia
fore, premixed insulin regimens are not inhibitors should be avoided in cases of (2). Episodes of hypoglycemia in the hos-
routinely recommended for in-hospital severe illness, in patients with ketonemia or pital should be documented in the medical
use. ketonuria, and during prolonged fasting and record and tracked (3).
surgical procedures (4). Until safety and
Type 1 Diabetes effectiveness are established, SGLT2 inhib-
For patients with type 1 diabetes, dosing itors are not recommended for routine Triggering Events and Prevention of
insulin based solely on premeal glucose in-hospital use. Furthermore, the FDA Hypoglycemia
levels does not account for basal insulin has recently warned that SGLT2 inhibitors Insulin is one of the most common drugs
requirements or caloric intake, increas- should be stopped 3 days before scheduled causing adverse events in hospitalized
ing the risk of both hypoglycemia and surgeries (4 days in the case of ertugliflozin). patients, and errors in insulin dosing and/
hyperglycemia. Typically, basal insulin or administration occur relatively fre-
dosing schemes are based on body HYPOGLYCEMIA quently (64–66). Beyond insulin dosing
weight, with some evidence that patients errors, common preventable sources of
Recommendations
with renal insufficiency should be treated iatrogenic hypoglycemia are improper
15.9 A hypoglycemia management
with lower doses (51,52). An insulin prescribing of other glucose-lowering med-
protocol should be adopted
regimen with basal and correction com- ications, inappropriate management of the
and implemented by each hos-
ponents is necessary for all hospitalized first episode of hypoglycemia, and nutri-
pital or hospital system. A plan
patients with type 1 diabetes, with the tion-insulin mismatch, often related to
for preventing and treating
addition of prandial insulin if the patient an unexpected interruption of nutrition.care.diabetesjournals.org Diabetes Care in the Hospital S215
A recent study describes acute kidney MEDICAL NUTRITION THERAPY IN (80,81). As outlined in Recommendation
injury as an important risk factor for hy- THE HOSPITAL 7.27, patients using diabetes devices
poglycemia in the hospital (67), possibly The goals of medical nutrition therapy in should be allowed to use them in an
as a result of decreased insulin clearance. the hospital are to provide adequate inpatient setting when proper supervi-
Studies of “bundled” preventive therapies, calories to meet metabolic demands, sion is available.
including proactive surveillance of glycemic optimize glycemic control, address per-
outliers and an interdisciplinary data- sonal food preferences, and facilitate STANDARDS FOR SPECIAL
driven approach to glycemic management, SITUATIONS
creation of a discharge plan. The ADA
showed that hypoglycemic episodes in does not endorse any single meal plan or Enteral/Parenteral Feedings
the hospital could be prevented. Com- specified percentages of macronutrients. For patients receiving enteral or paren-
pared with baseline, two such studies Current nutrition recommendations ad- teral feedings who require insulin, the
found that hypoglycemic events fell by vise individualization based on treatment regimen should include coverage of
56–80% (68,69). The Joint Commission goals, physiological parameters, and basal, prandial, and correctional needs
recommends that all hypoglycemic epi- medication use. Consistent carbohydrate (82,83). It is particularly important that
sodes be evaluated for a root cause and meal plans are preferred by many hos- patients with type 1 diabetes continue to
the episodes be aggregated and reviewed pitals as they facilitate matching the receive basal insulin even if feedings are
to address systemic issues (23). prandial insulin dose to the amount of discontinued.
In addition to errors with insulin treat- carbohydrate consumed (76). Most patients receiving basal insulin
ment, iatrogenic hypoglycemia may be Orders should also indicate that the should continue with their basal dose
induced by a sudden reduction of corti- meal delivery and nutritional insulin cov- while the dose of insulin for the total daily
costeroid dose, reduced oral intake, eme- erage should be coordinated, as their nutritional component may be calculated
sis, inappropriate timing of short- or variability often creates the possibility of as 1 unit of insulin for every 10–15 g
rapid-acting insulin in relation to meals, hyperglycemic and hypoglycemic events. carbohydrate in the formula. Commer-
reduced infusion rate of intravenous Many hospitals offer “meals on de- cially available cans of enteral nutrition
dextrose, unexpected interruption of en- mand,” allowing patients to order meals contain variable amounts of carbohy-
teral or parenteral feedings, delayed or from the menu at any time of the day. drate and may be infused at different
missed blood glucose checks, and altered This option improves patient satisfaction rates. All of this must be taken into
ability of the patient to report symptoms but complicates meal–insulin coordina- consideration while calculating insulin
(5). tion. Finally, if carbohydrate counting is doses to cover the nutritional compo-
provided by the hospital kitchen, this nent of enteral nutrition (77). Most spe-
Predictors of Hypoglycemia option should be used in patients count- cialists recommend using NPH insulin
In ambulatory patients with diabetes, it is ing carbohydrates at home (77). twice or three times daily (every 8 or
well established that an episode of severe 12 h) to cover patient needs. Adjust-
hypoglycemia increases the risk for a sub- ments in insulin doses must be made
sequent event, in part because of impaired SELF-MANAGEMENT IN THE frequently. Correctional insulin should
counterregulation (70,71). This relation- HOSPITAL also be administered subcutaneously
ship also holds for inpatients. For example, Diabetes self-management in the hospi- every 6 h using human regular insulin
in a study of hospitalized patients treated tal may be appropriate for specific pa- or every 4 h using a rapid-acting insulin. If
for hyperglycemia, 84% who had an epi- tients (78,79). Candidates include both enteral nutrition is interrupted, a 10%
sode of “severe hypoglycemia” (defined adolescent and adult patients who suc- dextrose infusion must be started imme-
as ,40 mg/dL [2.2 mmol/L]) had a pre- cessfully conduct self-management of diately to prevent hypoglycemia and to
ceding episode of hypoglycemia (,70 diabetes at home, and whose cognitive allow time to select more appropriate
mg/dL [3.9 mmol/L]) during the same and physical skills needed to successfully insulin doses.
admission (72). In another study of self-administer insulin and perform self- For patients receiving enteral bolus
hypoglycemic episodes (defined as ,50 monitoring of blood glucose are not feedings, approximately 1 unit of regular
mg/dL [2.8 mmol/L]), 78% of patients compromised. In addition, they should human insulin or rapid-acting insulin per
were using basal insulin, with the inci- have adequate oral intake, be proficient 10–15 g carbohydrate should be given
dence of hypoglycemia peaking between in carbohydrate estimation, use multiple subcutaneously before each feeding.
midnight and 6:00 A.M. Despite recognition daily insulin injections or continuous Correctional insulin coverage should
of hypoglycemia, 75% of patients did not subcutaneous insulin infusion (CSII), be added as needed before each feeding.
have their dose of basal insulin changed have stable insulin requirements, and In patients receiving nocturnal tube
before the next insulin administration (73). understand sick-day management. If feeding, NPH insulin administered with
Recently, several groups have devel- self-management is to be used, a pro- the initiation of feeding represents a
oped algorithms to predict episodes of tocol should include a requirement that reasonable approach to cover this nutri-
hypoglycemia among inpatients (74,75). the patient, nursing staff, and physician tional load.
Models such as these are potentially agree that patient self-management is For patients receiving continuous pe-
important and, once validated for gen- appropriate. If CSII or CGM is to be used, ripheral or central parenteral nutrition,
eral use, could provide a valuable tool to hospital policy and procedures delineat- human regular insulin may be added to
reduce rates of hypoglycemia in hospi- ing guidelines for CSII therapy, including the solution, particularly if .20 units of
talized patients. the changing of infusion sites, are advised correctional insulin have been requiredS216 Diabetes Care in the Hospital Diabetes Care Volume 44, Supplement 1, January 2021
in the past 24 h. A starting dose of 1 unit Perioperative Care (DKA) and hyperosmolar hyperglyce-
of human regular insulin for every 10 g Many standards for perioperative care mic states, ranging from euglycemia
dextrose has been recommended (84) lack a robust evidence base. However, or mild hyperglycemia and acidosis
and should be adjusted daily in the the following approach (92–94) may be to severe hyperglycemia, dehydration,
solution. Adding insulin to the parenteral considered: and coma; therefore, individualization
nutrition bag is the safest way to prevent of treatment based on a careful clinical
hypoglycemia if the parenteral nutrition 1. The target range for blood glucose in and laboratory assessment is needed
is stopped or interrupted. Correctional the perioperative period should be (98–101).
insulin should be administered subcuta- 80–180 mg/dL (4.4–10.0 mmol/L). Management goals include restora-
neously. For full enteral/parenteral feed- 2. A preoperative risk assessment should tion of circulatory volume and tissue
ing guidance, please refer to review be performed for patients with diabetes perfusion, resolution of hyperglycemia,
articles detailing this topic (82,85). who are at high risk for ischemic heart and correction of electrolyte imbalance
Because continuous enteral or paren- disease and those with autonomic neu- and acidosis. It is also important to treat
teral nutrition results in a continuous ropathy or renal failure. any correctable underlying cause of
postprandial state, any attempt to bring 3. Metformin should be withheld on the DKA such as sepsis, myocardial infarction,
blood glucose levels to below 140 mg/ day of surgery. or stroke. In critically ill and mentally
dL (7.8 mmol/L) substantially increases 4. SGLT2 inhibitors must be discontin- obtunded patients with DKA or hyper-
the risk of hypoglycemia in these ued 3–4 days before surgery. osmolar hyperglycemia, continuous intra-
patients. 5. Withhold any other oral glucose- venous insulin is the standard of care.
lowering agents the morning of sur- Successful transition of patients from
Glucocorticoid Therapy gery or procedure and give half of intravenous to subcutaneous insulin
The prevalence of glucocorticoid therapy NPH dose or 75–80% doses of long- requires administration of basal insulin
in hospitalized patients can approach acting analog or pump basal insulin. 2–4 h prior to the intravenous insulin
10%, and these medications can in- 6. Monitor blood glucose at least every being stopped to prevent recurrence
duce hyperglycemia in patients with and 2–4 h while patient is taking nothing of ketoacidosis and rebound hypergly-
without antecedent diabetes (86). Glu- by mouth and dose with short- or cemia (100). There is no significant
cocorticoid type and duration of action rapid-acting insulin as needed. difference in outcomes for intravenous
must be considered in determining in- 7. There are no data on the use and/or human regular insulin versus subcuta-
sulin treatment regimens. Daily-ingested influence of glucagon-like peptide 1 neous rapid-acting analogs when com-
short-acting glucocorticoids such as receptor agonists or ultra-long-acting bined with aggressive fluid management
prednisone reach peak plasma levels insulin analogs upon glycemia in peri- for treating mild or moderate DKA (102).
in 4–6 h (87) but have pharmacologic operative care. Patients with uncomplicated DKA may
actions that last through the day. Pa- sometimes be treated with subcutane-
tients on morning steroid regimens have A recent review concluded that peri- ous insulin in the emergency department
disproportionate hyperglycemia during operative glycemic control tighter than or step-down units (103), an approach
the day, but they frequently reach nor- 80–180 mg/dL (4.4–10.0 mmol/L) did that may be safer and more cost-
mal blood glucose levels overnight re- not improve outcomes and was asso- effective than treatment with intrave-
gardless of treatment (86). In subjects on ciated with more hypoglycemia (95); nous insulin. If subcutaneous insulin ad-
once- or twice-daily steroids, administra- therefore, in general, tighter glycemic ministration is used, it is important to
tion of intermediate-acting (NPH) insulin targets are not advised. Evidence from a provide adequate fluid replacement, fre-
is a standard approach. NPH is usually recent study indicates that compared quent bedside testing, appropriate treat-
administered in addition to daily basal- with usual dosing, a reduction of insulin ment of any concurrent infections, and
bolus insulin or in addition to oral anti- given the evening before surgery by appropriate follow-up to avoid recur-
diabetes medications. Because NPH ac- ;25% was more likely to achieve peri- rent DKA. Several studies have shown
tion peaks at 4–6 h after administration, operative blood glucose levels in the target that the use of bicarbonate in patients
it is best to give it concomitantly with range with lower risk for hypoglycemia (96). with DKA made no difference in reso-
steroids (88). For long-acting glucocorti- In noncardiac general surgery patients, lution of acidosis or time to discharge,
coids such as dexamethasone and mul- basal insulin plus premeal short- or rapid- and its use is generally not recommen-
tidose or continuous glucocorticoid acting insulin (basal-bolus) coverage has ded. For further information regarding
use, long-acting insulin may be re- been associated with improved glycemic treatment, refer to recent in-depth re-
quired to control fasting blood glucose control and lower rates of periopera- views (4).
(41,89). For higher doses of glucocorti- tive complications compared with the
coids, increasing doses of prandial and reactive, sliding scale regimens (short- or TRANSITION FROM THE HOSPITAL
correctional insulin, sometimes in ex- rapid-acting insulin coverage only with TO THE AMBULATORY SETTING
traordinary amounts, are often needed no basal insulin dosing) (47,97).
Recommendation
in addition to basal insulin (90,91).
15.11 There should be a structured
Whatever orders are started, adjust- Diabetic Ketoacidosis and
discharge plan tailored to the
ments based on anticipated changes in Hyperosmolar Hyperglycemic State
individual patient with diabetes.
glucocorticoid dosing and POC glucose There is considerable variability in the
B
test results are critical. presentation of diabetic ketoacidosiscare.diabetesjournals.org Diabetes Care in the Hospital S217
A structured discharge plan tailored to medications were stopped and to en- disease burden for patients and has im-
the individual patient may reduce length sure the safety of new prescriptions. portant financial implications. Of patients
of hospital stay and readmission rates c Prescriptions for new or changed med- with diabetes who are hospitalized, 30%
and increase patient satisfaction (104). ication should be filled and reviewed have two or more hospital stays, and these
Discharge planning should begin at ad- with the patient and family at or admissions account for over 50% of in-
mission and be updated as patient needs before discharge. patient costs for diabetes (108). Factors
change. contributing to readmission include male
Transition from the acute care setting Structured Discharge Communication sex, longer duration of prior hospitaliza-
presents risks for all patients. Inpatients c Information on medication changes, tion, number of previous hospitalizations,
may be discharged to varied settings, pending tests and studies, and follow- number and severity of comorbidities, and
including home (with or without visiting up needs must be accurately and lower socioeconomic and/or educational
nurse services), assisted living, rehabili- promptly communicated to outpa- status; scheduled home health visits and
tation, or skilled nursing facilities. For the tient physicians. timely outpatient follow-up reduce rates of
patient who is discharged to home or to c Discharge summaries should be trans- readmission (106,107). While there is no
assisted living, the optimal program will mitted to the primary care provider as standard to prevent readmissions, several
need to consider diabetes type and se- soon as possible after discharge. successful strategies have been reported
verity, effects of the patient’s illness on c Scheduling follow-up appointments (107). These include targeting ketosis-
blood glucose levels, and the patient’s prior to discharge increases the likeli- prone patients with type 1 diabetes
capacities and preferences. See Section hood that patients will attend. (109), insulin treatment of patients with
12 “Older Adults” (https://doi.org/10 admission A1C .9% (75 mmol/mol) (110),
.2337/dc21-S012) for more information. It is recommended that the following and use of a transitional care model (111).
An outpatient follow-up visit with the areas of knowledge be reviewed and For people with diabetic kidney disease,
primary care provider, endocrinologist, addressed prior to hospital discharge: collaborative patient-centered medical
or diabetes care and education specialist homes may decrease risk-adjusted read-
within 1 month of discharge is advised for c Identification of the health care pro- mission rates (112). A recently published
all patients experiencing hyperglycemia vider who will provide diabetes care algorithm based on patient demographic
in the hospital. If glycemic medications after discharge. and clinical characteristics had only mod-
are changed or glucose control is not c Level of understanding related to the erate predictive power but identifies a
optimal at discharge, an earlier appoint- diabetes diagnosis, self-monitoring of promising future strategy (113).
ment (in 1–2 weeks) is preferred, and blood glucose, home blood glucose Age is also an important risk factor in
frequent contact may be needed to avoid goals, and when to call the provider. hospitalization and readmission among
hyperglycemia and hypoglycemia. A c Definition, recognition, treatment, and patients with diabetes (refer to Section
recently described discharge algorithm prevention of hyperglycemia and 12 “Older Adults,” https://doi.org/10
for glycemic medication adjustment hypoglycemia. .2337/dc21-S012, for detailed criteria).
based on admission A1C was found c Information on making healthy food
useful to guide treatment decisions choices at home and referral to an References
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