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

The Burden of Prediabetes

Prevalence

Prediabetes is a condition defined by the presence of impaired fasting glucose (IFG) and/or impaired glucose tolerance (IGT) that has not yet reached the threshold for type 2 diabetes mellitus (T2D); the metabolic syndrome is also considered a prediabetes equivalent (1,2). Prediabetes raises short-term absolute risk of T2D by 3- to 10-fold (2). In the United States, 86 million people, or 37% of the US population, have prediabetes, and it is estimated that up to 70% of people with prediabetes may develop T2D during their lifetimes (3,4).

Screening and Monitoring of Prediabetes

AACE recommends that individuals who meet any of the clinical risk criteria noted below should be screened for prediabetes or type 2 diabetes (T2D)1.

Common Comorbidities and Complications of Prediabetes

Obesity 
Obesity is a neuroendocrine disease that is itself associated with numerous metabolic and biomechanical complications. It is generally defined as a body mass index (BMI) ≥30 kg/m2, especially in the presence of obesity-related complications. In the context of prediabetes, obesity (1-3):

Management of Prediabetes

Treatment Goals 
The primary goal of prediabetes management is to normalize glucose levels and prevent or delay progression to diabetes and associated microvascular complications (1,2). Management of common prediabetes comorbidities such as obesity, hypertension, dyslipidemia, cardiovascular disease, and chronic kidney disease is also essential.

The Burden of Diabetes

Epidemiology

Diabetes affects 9.4% of the population of the United States, or approximately 30.3 million people. Of these, 7.2 million have not been diagnosed. Approximately 90% of all diabetes cases are type 2 diabetes.1

Type 1 Diabetes Pathophysiology

Type 1 diabetes (T1D) is a chronic autoimmune disorder that occurs in genetically susceptible individuals and that may be precipitated by environmental factors. In a susceptible individual, the immune system is triggered to develop an autoimmune response against altered pancreatic beta cell antigens, or molecules in beta cells that resemble a viral protein. Approximately 85% of T1D patients have circulating islet cell antibodies, and the majority of patients also have detectable anti-insulin antibodies.

Type 1 Diabetes Diagnosis

Patients with type 1 diabetes (T1D) require exogenous insulin for survival and should be identified as soon as possible to avoid high morbidity due to a delay in insulin treatment.

Treatment of Type 1 Diabetes

Goals

  • Utilize intensive therapy aimed at near-normal BG and A1C levels
  • Prevent diabetic ketoacidosis and severe hypoglycemia
  • Achieve the highest quality of life compatible with the daily demands of diabetes management
  • In children, achieve normal growth and physical development and psychological maturation
  • Establish realistic goals adapted to each individual’s circumstances

Clinical Presentation of Type 2 Diabetes Mellitus

Risk Factors

The risk factors for the development of both prediabetes and type 2 diabetes mellitus (T2DM) are as follows:1

Diagnosis of Type 2 Diabetes Mellitus

There is a continuum of risk for poor patient outcomes as glucose tolerance progresses from normal to overt type 2 diabetes.

Type 2 Diabetes Glucose Management Goals

Optimal management of type 2 diabetes requires treatment of the “ABCs” of diabetes: A1C, blood pressure, and cholesterol (ie, dyslipidemia). This web page provides the rationale and targets for glucose management; AACE guidelines for blood pressure and lipid control are summarized in Management of Common Comorbidities of Diabetes.

Glycemic Management in Type 2 Diabetes

The Comprehensive Care Plan

Every patient with documented type 2 diabetes (T2D) should have a comprehensive care plan (CCP), which takes into account the patient’s unique medical history, behaviors and risk factors, ethnocultural background, and environment. The ultimate goal of the CCP is to reduce the risk of diabetes complications without jeopardizing patient safety. To achieve this goal, the CCP should include the following components:1

Management of Common Co-morbidities of Diabetes

As may be expected with a chronic disease that primarily affects middle-aged and older individuals, type 2 diabetes is usually complicated by other medical conditions. In the 1999-2004 cohort of the National Health and Nutrition Examination Survey (NHANES), only 14% of patients with type 2 diabetes had no other comorbidities.1Here we briefly outline management recommendations for major comorbidities of patients diagnosed with diabetes—the management recommendations are the same whether patients have type 1 or type 2 diabetes mellitus (T1DM and T2DM).

Diabetes and Cancer

Epidemiologic data have demonstrated significant increases of various cancers in people with obesity and diabetes. Recently, concern has emerged that antihyperglycemic medications may also be associated with an increased prevalence of multiple cancers; however, available data are limited and conflicting.1,2

Team Approach to Type 2 Diabetes Management

Comprehensive care of patients with diabetes requires a team of healthcare professionals. Working with different healthcare providers allows the patient to learn in-depth information regarding their health and well-being. It also ensures that the patient’s needs are cared for and addressed. It is important to use other providers’ skills and specialties to ensure patients have the best care and understanding of their condition. Often, problems may be apparent to one healthcare provider, but go unnoticed by another.

The Burden of Diabetes in Pregnancy

Epidemiology

Three types of diabetes may complicate pregnancy: preexisting type 1 diabetes mellitus (T1DM), type 2 diabetes mellitus (T2DM), or gestational diabetes mellitus (GDM). By definition, the first two types of diabetes are already established prior to pregnancy. GDM, also referred to as hyperglycemia in pregnancy, is a condition in which glucose intolerance develops in a patient who has not been previously diagnosed with diabetes.1,2

Identification, Screening, and Diagnosis of Diabetes in Pregnancy

GDM Definition, Etiology, Risk Factors, and Pathophysiology

Definition

Gestational diabetes mellitus (GDM) has been defined as any degree of carbohydrate intolerance with onset during pregnancy. This definition is a misnomer in that it includes unrecognized overt diabetes that may have been present prior to pregnancy as well as hyperglycemia that develops during pregnancy. Preexisting type 2 diabetes can often present as severe hyperglycemia during pregnancy.

Management of Pregnancy Complicated by Diabetes

Preconception Care

AACE guidelines specify that preconception care is important for all women with preexisting type 1 diabetes mellitus (T1DM) or type 2 diabetes mellitus (T2DM) or previous gestational diabetes mellitus (GDM). One of the primary goals of preconception care is to educate patients about strategies to maintain adequate nutrition and glu­cose control before conception, during pregnancy, and in the postpartum period.1