Clinical Evidence for Glucose Control in the Inpatient Setting

Key Points

  • Epidemiologic studies show that glucose control in hospitals is woefully inadequate.

    • Approximately 30% of hospitalized patients have blood glucose values >180 mg/dL.

      • As glucose levels rise, so does mortality risk, as well as the risk of dehydration, hypotension, eventual renal shutdown, poor healing, and impaired immune system function.

Mechanisms of Adverse Effects of Hyperglycemia in Acute Illness: A Review of the Basic Science

Key Points

  • Hyperglycemia and insulin regulation play both a direct and indirect role in the cellular mechanisms underlying inflammation and oxidative stress.

  • Free fatty acids generated by hyperglycemia and insulin deficiency also result in endothelial dysfunction and the generation of reactive oxygen species.

  • Hyperglycemia consistently promotes inflammation.

  • The role of insulin in mediating inflammation is more complicated.

Financial Impact of Inpatient Glycemic Control: Opportunities for Clinical and Financial Improvement

Key Points

  • Diabetes is an increasingly prevalent diagnosis among hospitalized patients.

    • Many patients have unrecognized diabetes.

  • Diabetes contributes to greater lengths of stay and increased costs among hospitalized patients.

  • Identifying and treating diabetes:

    • Reduces risk of serious and expensive complications

    • Reduces length of stay

    • Improves the bottom line

Management of Hyperglycemia in the Critical Care Setting

Key Points

  • Hyperglycemia is common in critically ill patients, both with and without diabetes.

  • Hyperglycemia is a predictor of adverse outcomes, including mortality.

  • Significant improvements in mortality and morbidity with intensive glycemic management have been demonstrated in some randomized, controlled trials and in “before and after” comparisons such as the Mixed Med-Surg ICU study.

  • Glycemic goals for critically ill patients:

    • Target blood glucose range is 140-180 mg/dL.

Management of Hyperglycemia in the Noncritical Care Setting

Key Points

  • Hyperglycemia is associated with poor outcomes in noncritically ill patients.

  • Glycemic goals for noncritically ill patients

    • Premeal blood glucose: <140 mg/dL

    • Random blood glucose: <180 mg/dL

    • Reassess insulin regimen if blood glucose is <100 mg/dL, and adjust insulin regimen if blood glucose is <70 mg/dL (unless explained by a missed meal or other specific factors)

Diagnosis and Management of Hyperglycemic Crises: Diabetic Ketoacidosis and the Hyperglycemic Hyperosmolar State

Key Points

  • DKA and HHS are life-threatening emergencies.

  • Management involves

    • Attention to precipitating cause

    • Fluid and electrolyte management

    • Insulin therapy

    • Patient monitoring

    • Prevention of metabolic complications during recovery

    • Transition to long-term therapy

  • Patient education and discharge planning should aim at prevention of recurrence.

Management of Inpatient Hyperglycemia in Special Populations

Hyperglycemia is associated with adverse clinical outcomes in the hospital setting, both in critically ill and noncritically ill patients.

Avoiding Hypoglycemia in the Hospital Setting

Key Points

  • Various patient- and provider-specific factors may increase the risk of inpatient hypoglycemia

Safety Concerns With Insulin Use in the Inpatient Setting: The Pharmacist’s Role

Key Points

  • Insulin is the most appropriate agent for the majority of hospitalized patients.

  • Insulin is a “high-alert medication.”

Role of Nursing in the Continuum of Inpatient Diabetes Care

Key Points

  • Nurses are essential—and central—to successful implementation of protocols, order sets, glucose monitoring, and educational programs to support improved glycemic control.

  • Because nurses oversee inpatient care on a 24-hour basis (regardless of the nursing system structure), nurses have opportunities to coordinate care of patients with hyperglycemia.

  • The individual nurses who will be most involved in implementing these systems should also be involved in planning, design, and evaluation of any new method for delivery of care.

Glycemic Control During Labor and Delivery

Key Points

  • The last 18 hours in utero have a significant impact on the infant’s metabolic responses after birth, even if maternal glucose control is adequate over the duration of gestation.

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)

Successful Models of Implementation

Key Points

  • Hyperglycemia in the hospital affects quality of care, patient safety, length of stay, and cost; hence, addressing hyperglycemia in hospitalized patients can unite professionals in a common quest.

  • Models for implementation of improved control of hyperglycemia include:

    • Consultant Model
    • Diabetes Team Model
    • System-Wide Model

  • It is important to adapt the model you choose to fit your particular institution’s needs.

  • Critical success factors often include:

Glucometrics: Assessing Quality in Inpatient Glycemic Management

Glucometrics is a way to measure the success of inpatient glucose management. Getting timely and accurate metrics to frontline clinical teams, which can analyze the results and look for cause and effect, will transform performance improvement into optimal outcomes.

Strategies for Effective Discharge Planning for Hospitalized Patients With Diabetes

Key Points

  • Upon admission (or as soon thereafter as possible), every patient’s need for diabetes education should be assessed.

  • During hospital stay, all patients with diabetes should receive necessary training in diabetes knowledge and self-care skills.

  • Upon discharge, patients should receive a post-discharge plan for diabetes management, including clear instructions about medications:

    • Name of medication

    • Dosage of medication

    • Dosing schedule

Clinical Evidence for Glucose Control in the Inpatient Setting

Key Points

  • Epidemiologic studies show that glucose control in hospitals is woefully inadequate.

    • Approximately 30% of hospitalized patients have blood glucose values >180 mg/dL.

      • As glucose levels rise, so does mortality risk, as well as the risk of dehydration, hypotension, eventual renal shutdown, poor healing, and impaired immune system function.

Mechanisms of Adverse Effects of Hyperglycemia in Acute Illness: A Review of the Basic Science

Key Points

  • Hyperglycemia and insulin regulation play both a direct and indirect role in the cellular mechanisms underlying inflammation and oxidative stress.

  • Free fatty acids generated by hyperglycemia and insulin deficiency also result in endothelial dysfunction and the generation of reactive oxygen species.

  • Hyperglycemia consistently promotes inflammation.

  • The role of insulin in mediating inflammation is more complicated.

Financial Impact of Glycemic Control: Opportunities for Clinical and Financial Improvement

Key Points

  • Diabetes is an increasingly prevalent diagnosis among hospitalized patients.

    • Many patients have unrecognized diabetes.

  • Diabetes contributes to greater lengths of stay and increased costs among hospitalized patients.

  • Identifying and treating diabetes:

    • Reduces risk of serious and expensive complications

    • Reduces length of stay

    • Improves the bottom line

Management of Hyperglycemia in the Critical Care Setting

Key Points

  • Hyperglycemia is common in critically ill patients, both with and without diabetes.

  • Hyperglycemia is a predictor of adverse outcomes, including mortality.

  • Significant improvements in mortality and morbidity with intensive glycemic management have been demonstrated in some randomized, controlled trials and in “before and after” comparisons such as the Mixed Med-Surg ICU study.

Management of Hyperglycemia in the Noncritical Care Setting

Key Points

  • Hyperglycemia is associated with poor outcomes in noncritically ill patients.

  • Glycemic goals for noncritically ill patients

    • Premeal blood glucose: <140 mg/dL

    • Random blood glucose: <180 mg/dL

    • Reassess insulin regimen if blood glucose is <100 mg/dL, and adjust insulin regimen if blood glucose is <70 mg/dL (unless explained by a missed meal or other specific factors)

Diagnosis and Management of Hyperglycemic Crises: Diabetic Ketoacidosis and the Hyperglycemic Hyperosmolar State

Key Points

  • DKA and HHS are life-threatening emergencies.

  • Management involves

    • Attention to precipitating cause

    • Fluid and electrolyte management

    • Insulin therapy

    • Patient monitoring

    • Prevention of metabolic complications during recovery

    • Transition to long-term therapy

Management of Inpatient Hyperglycemia in Special Populations

Key Points

  • Hyperglycemia is associated with adverse clinical outcomes in the hospital setting, both in critically ill and noncritically ill patients.

  • National organizations have promoted safe and achievable glucose targets for inpatients.

  • Special considerations are necessary for patients

    • On enteral or parenteral nutrition

    • Receiving steroids

    • Using insulin pumps

Avoiding Hypoglycemia in the Hospital Setting

Key Points

  • Various patient- and provider-specific factors may increase the risk of inpatient hypoglycemia

  • Hypoglycemia is costly

    • - Patient level: increases risk of complications

    • - Institutional level: increases cost of care and may reduce reimbursement (Medicare “never” event)

  • Intensive insulin therapy increases the risk of severe hypoglycemia but not hypoglycemia-associated mortality

Safety Concerns With Insulin Use in the Inpatient Setting: The Pharmacist’s Role

Key Points

  • Insulin is the most appropriate agent for the majority of hospitalized patients.

  • Insulin is a “high-alert medication.”

  • For effective and safe use of insulin, institutions need to consider

    • Standardized pharmacy operations

    • Education of nursing and support staff

    • Implementation of hospital-wide initiatives

    • Effective communication and collaboration among caregivers

Role of Nursing in the Continuum of Inpatient Diabetes Care

Key Points

  • Nurses are essential—and central—to successful implementation of protocols, order sets, glucose monitoring, and educational programs to support improved glycemic control.

  • Because nurses oversee inpatient care on a 24-hour basis (regardless of the nursing system structure), nurses have opportunities to coordinate care of patients with hyperglycemia.

Glycemic Control During Labor and Delivery

Key Points

  • The last 18 hours in utero have a significant impact on the infant’s metabolic responses after birth, even if maternal glucose control is adequate over the duration of gestation.

    • Neonatal hypoglycemia is directly and inversely related to maternal hyperglycemia during labor. With maternal hyperglycemia, the compensatory fetal hyperinsulinemia will result in hypoglycemia upon cutting of the umbilical cord, since the source of incoming glucose will no longer be present.

Successful Models of Implementation

Key Points

  • Hyperglycemia in the hospital affects quality of care, patient safety, length of stay, and cost; hence, addressing hyperglycemia in hospitalized patients can unite professionals in a common quest.

  • Models for implementation of improved control of hyperglycemia include:

    • Consultant Model

    • Diabetes Team Model

    • System-Wide Model

  • It is important to adapt the model you choose to fit your particular institution’s needs.

Glucometrics: Assessing Quality in Inpatient Glycemic Management

Key Points

  • Glucometrics is a way to measure the success of inpatient glucose management. Getting timely and accurate metrics to frontline clinical teams, which can analyze the results and look for cause and effect, will transform performance improvement into optimal outcomes.

  • Glucometrics generally consists of 3 measures:

    • Glycemic exposure

    • Efficacy of control

    • Rate of adverse events

Strategies for Effective Discharge Planning for Hospitalized Patients With Diabetes

Key Points

  • Upon admission (or as soon thereafter as possible), every patient’s need for diabetes education should be assessed.

  • During hospital stay, all patients with diabetes should receive necessary training in diabetes knowledge and self-care skills.

  • Upon discharge, patients should receive a post-discharge plan for diabetes management, including clear instructions about medications:

    • Name of medication

    • Dosage of medication

    • Dosing schedule