final standalone management of hyperglycemia guideline

7/27/2019 FINAL Standalone Management of Hyperglycemia Guideline

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Management of Hyperglycemiain Hospitalized Patientsin Non-Critical Care Setting:

An Endocrine Society Clinical Practice Guideline

T h e E n d o c r i n e S o c i e t y s

CC Gs


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Authors: Guillermo . mpierrez, Richard Hellman, Mary T. Korytkowki, Mikhail Koiborod, Gregory .

Maynard,VictorM.Montori,JaneJ.seley,andGreetVandenBerghe

Afliations:moryniverityschoolofMedicine(G...),tlanta,Georgia30322;HeartofmericaiabeteReearch Foundation and niverity of Miouri-Kana Cityschool of Medicine (R.H.), orth Kana City,

Miouri64112;niverity ofPittburgh school ofMedicine(M.T.K.),Pittburgh,Pennylvania15213;saint

ukeMid-mericaHeartntituteandniverityofMiouri-KanaCity(M.K.),KanaCity,Miouri64111;

niverityofCaliforniasaniegoMedicalCenter(G..M.),saniego,California92037;MayoClinicRocheter

(V.M.M.),Rocheter,Minneota55905;ewYork-PrebyterianHopital/WeillCornellMedicalCenter(J.J.s.),

ewYork,ewYork10065;andCatholicniverityofeuven(G.V.d.B.),3000euven,Belgium

Co-Sponsoring Associations: merican iabete ociation, merican Heart ociation, merican

ociationofiabeteducator,uropeansocietyofndocrinology,societyofHopitalMedicine.

Disclaimer: ClinicalPracticeGuidelinearedevelopedto beofaitanceto endocrinologitandotherhealth

careprofeionalbyprovidingguidanceandrecommendationforparticularareaofpractice.TheGuideline

houldnotbe conideredincluiveofallproperapproacheormethod,orexcluiveof other.TheGuideline

cannotguaranteeanypecicoutcome,nordotheyetablihatandardofcare.TheGuidelinearenotintended

to dictate thetreatmentof a particular patient.Treatment deciionmut be madebaed on theindependent

judgmentofhealthcareproviderandeachpatientindividualcircumtance.

The ndocrine society make no warranty, expre or implied, regarding the Guideline and pecically

excludeanywarrantieofmerchantabilityandtneforaparticularueorpurpoe.Thesocietyhallnotbeliable

for direct, indirect, pecial, incidental, or conequential damage related to the ue of the information

containedherein.

FirtpublihedinJournal of Clinical Endocrinology & Metabolism, January 2012, 97 (1):1638.

Thendocrinesociety,2012


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Management of Hyperglycemiain Hospitalized Patientsin Non-Critical Care Setting:

An Endocrine Society Clinical Practice Guideline

T h e E n d o c r i n e S o c i e t y s

CC Gs


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Table of Contents

btract. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

summaryofRecommendation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

Methodofevelopmentofvidence-BaedClinicalPracticeGuideline. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

iagnoiandRecognitionofHyperglycemiaandiabeteintheHopitalsetting. . . . . . . . . . . . . . . . . . . . . . . .8

MonitoringGlycemiaintheon-CriticalCaresetting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

GlycemicTargetintheon-CriticalCaresetting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

ManagementofHyperglycemiaintheon-CriticalCaresetting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

specialsituation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

RecognitionandManagementofHypoglycemiaintheHopitalsetting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

mplementationofaGlycemicControlProgramintheHopital. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

PatientandProfeionalducation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Reference. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

OrderForm. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35

Reprintnformation,Quetion&Correpondence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . nideBackCover


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3

M

anageM

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of

HyperglyceM

iainHospitalizedpati

entsinnon-critical

caresetting

Abstract

Objective: The aim wa to formulate practiceguideline on the management of hyperglycemia in

hopitalizedpatientinthenon-criticalcareetting.

Participants:TheTakForcewacompoedofachair,elected by the Clinical Guideline subcommittee

ofThendocrinesociety,ixadditionalexpert,and

amethodologit.

Evidence: Thievidence-baedguidelinewa devel-opeduingtheGradingofRecommendation,e-

ment, evelopment, and valuation (GR)

ytemtodecribeboththetrengthofrecommenda-

tionandthequalityofevidence.

Consensus Process: One group meeting, everalconferencecall,ande-mailcommunicationenabled

conenu. ndocrine society member, mericaniabete ociation, merican Heart ociation,

merican ociation of iabete ducator, uro-

pean society of ndocrinology, and the society of

Hopital Medicine reviewed and commented on

preliminarydraftofthiguideline.

Conclusions: Hyperglycemiaiacommon,eriou,and cotly health care problem in hopitalized

patient. Obervational and randomized controlled

tudie indicate that improvement in glycemic

control reult in lower rate of hopital complica-

tioningeneralmedicineandurgerypatient.mple-

mentingatandardizedcinulinorderetpromoting

the ue of cheduled baal and nutritional inulin

therapyiakeyinterventionintheinpatientmanage-

mentofdiabete.Weproviderecommendationfor

practical, achievable,and afe glycemic targetand

decribeprotocol,procedure,andytemimprove-

ment required to facilitate the achievement of

glycemic goal in patient with hyperglycemia and

diabeteadmittedinnon-criticalcareetting.

J Clin Endocrinol Metab, January 2012, 97

(1):1638.

Abbreviations: BG, Blood glucose; CII, continuous insulin infusion; EN, enteral nutrition; HbA1C, hemoglobin A1C; ICU, intensive care unit; MNT,medical nutrition therapy; NPH, neutral protamine Hagedorn; NPO, nil per os (nothing by mouth); PN, parenteral nutrition; POC, point of care; SSI,sliding scale insulin; TZD, thiazolidinedione.


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SMMA O

ECOMMENATONS

1.0. iagnosis and recognition of hyperglycemiaand diabetes in the hospital setting

1.1. Werecommendthatclinicianaeallpatient

admitted to the hopital for a hitory of diabete.

Whenpreent,thidiagnoihouldbeclearlyidenti-

edinthemedicalrecord.(1| )

1.2. Weuggetthatallpatient,independentofa

prior diagnoi of diabete, have laboratory blood

glucoe(BG)tetingonadmiion.(2| )

1.3. Werecommendthatpatientwithoutahitoryof diabete with BG greater than 7.8 mmol/liter

(140mg/dl)bemonitoredwithbedidepointofcare

(POC)tetingforatleat24to48h.ThoewithBG

greater than 7.8 mmol/liter require ongoing POC

teting with appropriate therapeutic intervention.

(1| )

1.4. We recommend that in previouly normogly-

cemic patient receiving therapie aociated with

hyperglycemia,uchacorticoteroidoroctreotide,

enteralnutrition()andparenteralnutrition(P)bemonitored withbedide POCtetingforat leat

24to48hafterinitiationoftheetherapie.Thoe

with BG meaure greater than 7.8 mmol/liter

(140mg/dl)requireongoingPOCtetingwithappro-

priatetherapeuticintervention.(1| )

1.5. Werecommendthatallinpatientwithknown

diabete or with hyperglycemia (> 7.8 mmol/liter)

beaeedwithahemoglobin1C(Hb1C)level

if thi ha not been performed in the preceding

23month.(1| )

2.0. Monitoring glycemia in the non-criticalcare setting

2.1. We recommend bedide capillary POC

tetingathepreferredmethodforguidingongoing

glycemic management of individual patient.

(1| )

2.2. We recommend the ue of BG monitoring

device that have demontrated accuracy of ue in

acutelyillpatient.(1| )

2.3. Werecommendthattimingofglucoemeaure

match the patient nutritional intakeand medica-

tionregimen.(1| )

2.4. We ugget the following chedule for POC

teting:beforemealandatbedtimeinpatientwho

areeating,orevery46hinpatientwhoarePO

[receivingnothingbymouth(nilpero)]orreceiving

continuouenteralfeeding.(2| )

3.0. Glycemic targets in the non-criticalcare setting

3.1. We recommend a premeal glucoe target oflethan140mg/dl(7.8mmol/liter)andarandom

BGoflethan180mg/dl(10.0mmol/liter)forthe

majority of hopitalized patient with non-critical

illne.(1| )

3.2. We ugget that glycemic target be modied

accordingtoclinicaltatu.Forpatientwhoareable

to achieve and maintain glycemic control without

hypoglycemia, a lower target range may be reaon-

able. For patient with terminal illne and/orwith

limited life expectancyor at high rik for hypogly-

cemia,ahighertargetrange(BG


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4.1.2. Weuggetthatprovidingmealwithaconi-

tent amount of carbohydrate at each meal can be

uefulincoordinatingdoeofrapid-actinginulinto

carbohydrateingetion.(2| )

4.2. Transition from home to hospital

4.2.1. We recommend inulin therapy a the

preferredmethodforachievingglycemiccontrolin

hopitalizedpatientwithhyperglycemia.(1| )

4.2.2. Weuggetthedicontinuationoforalhypo-

glycemic agent and initiation of inulin therapy

forthemajorityofpatientwithtype2diabeteat

thetime ofhopital admiion for an acute illne.

(2| )

4.2.3. Weuggetthatpatienttreatedwithinulinbefore admiion have their inulin doe modied

accordingtoclinicaltatuaawayofreducingthe

rikforhypoglycemiaandhyperglycemia.(2| )

4.3. Pharmacological therapy

4.3.1. Werecommendthatallpatientwithdiabete

treatedwithinulinathomebetreatedwithached-

uledcinulinregimeninthehopital.(1| )

4.3.2. Weuggetthatprolongedueoflidingcaleinulin(ss)therapybeavoidedatheolemethod

forglycemiccontrolinhyperglycemicpatientwith

hitoryofdiabeteduringhopitalization.(2| )

4.3.3. We recommend that cheduled c inulin

therapyconitofbaalorintermediate-actinginulin

givenonceortwiceadayincombinationwithrapid-

orhort-actinginulinadminiteredbeforemealin

patientwhoareeating.(1| )

4.3.4. Weuggetthatcorrectioninulinbeincludeda a component of a cheduled inulin regimen

fortreatmentofBGvalueabovethedeiredtarget.

(2| )

4.4. Transition from hospital to home

4.4.1. We ugget reintitution of preadmiion

inulin regimen or oral and non-inulin injectable

antidiabetic drug at dicharge for patient with

acceptable preadmiion glycemic control and

without a contraindication to their continued ue.

(2| )

4.4.2. Weuggetthatinitiationofinulinadmini-

trationbeintitutedatleatonedaybeforedicharge

toallowaementoftheefcacyandafetyofthitranition.(2| )

4.4.3. Werecommendthatpatientandtheirfamily

orcaregiverreceive both written andoralintruc-

tionregardingtheirglycemicmanagementregimen

atthetimeofhopitaldicharge.Theeintruction

needtobeclearlywritteninamannerthatiunder-

tandable to the peron who will adminiter thee

medication.(1| )

5.0. Special situations

5.1. Transition from iv continuous insulininfusion (C) to sc insulin therapy

5.1.1. Werecommendthatallpatientwithtype1

andtype2 diabete betranitionedto cheduledc

inulintherapyatleat12hbeforedicontinuation

ofC.(1| )

5.1.2. We recommend that c inulin be admini-

tered before dicontinuation of C for patientwithoutahitoryofdiabetewhohavehyperglycemia

requiringmorethan2/h.(1| )

5.1.3. We recommend POC teting with daily

adjutmentoftheinulinregimenafterdicontinua-

tionofC.(1| )

5.2. Patients receiving EN or PN

5.2.1. WerecommendthatPOCtetingbeinitiated

for patient with or without a hitory of diabetereceivingandP.(1| )

5.2.2. WeuggetthatPOCtetingcanbedicon-

tinuedinpatientwithoutapriorhitoryofdiabete

ifBGvaluearelethan7.8mmol/liter(140mg/dl)

without inulin therapy for 2448 h after achieve-

mentofdeiredcaloricintake.(2| )

5.2.3. Weuggetthatcheduledinulintherapybe

initiatedinpatientwithandwithoutknowndiabete


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6.0. ecognition and management ofhypoglycemia in the hospital setting

6.1. We recommend that glucoe management

protocol with pecic direction for hypoglycemia

avoidanceandhypoglycemiamanagementbeimple-

mentedinthehopital.(1| )

6.2. Werecommendimplementationofatandarized

hopital-wide, nure-initiated hypoglycemia treat-

ment protocol to prompt immediate therapy of

anyrecognizedhypoglycemia,denedaaBGbelow

3.9mmol/liter(70mg/dl).(1| )

6.3. Werecommendimplementationofaytemfor

trackingfrequencyofhypoglycemiceventwithroot

caueanalyiofeventaociatedwithpotentialfor

patientharm.(1| )

7.0. mplementation of a glycemic controlprogram in the hospital

7.1. Werecommendthathopitalprovideadmini-

trative upport for an interdiciplinary teering

committeetargetingaytemapproachtoimprove

careofinpatientwithhyperglycemiaanddiabete.

(1| )

7.2. Werecommendthateachintitutionetablihauniform method of collecting andevaluating POC

tetingdataandinulinueinformationaawayof

monitoring the afety and efcacy of the glycemic

controlprogram.(1| )

7.3. We recommend that intitution provide

accurate device for glucoe meaurement at the

bedidewithongoingtaffcompetencyaement.

(1| )

8.0. Patient and professional education

8.1. We recommend diabete elf-management

education targeting hort-term goal that focu on

urvival kill: baic meal planning, medication

adminitration, BG monitoring, and hypoglycemia

andhyperglycemiadetection,treatment,andpreven-

tion.(1| )

8.2. We recommend identifying reource in the

community to which patient can be referred for

whohavehyperglycemia,denedaBGgreaterthan

7.8mmol/liter(140mg/dl),andwhodemontratea

peritentrequirement(i.e.>12to24h)forcorrec-

tioninulin.(2| )

5.3. Perioperative BG control

5.3.1. Werecommendthatallpatientwithtype1

diabete who undergo minor or major urgical

procedurereceiveeitherCorcbaalinulinwith

bolu inulin a required to prevent hyperglycemia

duringtheperioperativeperiod.(1| )

5.3.2. Werecommenddicontinuationoforaland

noninulin injectable antidiabetic agent before

urgery with initiation of inulin therapy in thoe

whodevelophyperglycemiaduringtheperioperativeperiodforpatientwithdiabete.(1| )

5.3.3. When intituting c inulin therapy in the

poturgical etting, we recommend that baal (for

patientwhoarePO)orbaalbolu(forpatient

whoareeating)inulintherapybeintitutedathe

preferredapproach.(1| )

5.4. Glucocorticoid-induced diabetes

5.4.1. WerecommendthatbedidePOCtetingbeinitiated for patient with or without a hitory of

diabetereceivingglucocorticoidtherapy.(1| )


tinued innondiabetic patient ifall BG reult are

below 7.8 mmol/liter (140 mg/dl) without inulin

therapyforaperiodofatleat2448h.(2| )

5.4.3. Werecommendthatinulintherapybeiniti-

atedforpatientwithperitenthyperglycemiawhile

receivingglucocorticoidtherapy.(1| )

5.4.4. WeuggetCaanalternativetocinulin

therapyforpatientwithevereandperitenteleva-

tioninBGdepiteueofcheduledbaalboluc

inulin.(2| )


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panelitconideredinmakingtherecommendation;

in ome intance, there are remark, a ection in

whichpanelitoffertechnicaluggetionforteting

condition,doing,andmonitoring.Theetechnical

commentreectthebetavailableevidenceapplied

toatypicalperonbeingtreated.Oftenthievidence

come from the unytematic obervation of the

panelitandtheirvalueandpreference;therefore,

theeremarkhouldbeconidereduggetion.

The prevalence of diabete ha reached epidemic

proportion in the nited state. The Center for

ieae Control and Prevention recently reported

that25.8millionpeople,or8.3%ofthepopulation,

have diabete (3). iabete repreent the eventh

leadingcaueofdeath(4)andithefourthleading

comorbidconditionamonghopitaldichargeinthenitedstate(5).pproximatelyoneinfourpatient

admitted to the hopital ha a known diagnoi of

diabete (6, 7), and about 30% of patient with

diabeterequiretwoormorehopitalizationinany

givenyear(7).Theprevalenceofdiabeteihigher

in elderly patient and reident of long-term-care

facilitie,inwhomdiabeteireportedinuptoone

thirdofadultaged6575yrandin40%ofthoe

olderthan80yr(8,9).

The aociation between hyperglycemia in hopi-

talized patient (with or without diabete) and

increaed rik for complication and mortality i

well etablihed (6, 1014). Thi aociation i

oberved for both admiion glucoe andmean BG

level during the hopital tay. lthough mot

randomizedcontrolledtrialinvetigatingtheimpact

of treating hyperglycemia on clinical outcome

havebeenperformedincriticallyillpatient,there

are extenive obervational data upporting the

importance of hyperglycemia management amongnon-critically ill patient admitted to general

medicine and urgery ervice. n uch patient,

hyperglycemiaiaociatedwithprolongedhopital

tay, increaed incidence of infection, and more

diability after hopital dicharge and death

(6,1519).Thimanucriptcontaintheconenu

recommendation for the management of hyper-

glycemia in hopitalized patient in non-critical

care etting by The ndocrine society and other

continuingdiabeteelf-managementeducationafter

dicharge.(1| )

8.3. We recommend ongoing taff education to

updatediabeteknowledge, awella targeted taff

education whenever an advere event related to

diabetemanagementoccur.(1| )

METHO O EEOPMENT

O EENCE-BASE CNCA

PACTCE GENES

The Clinical Guideline subcommittee of The

ndocrinesocietydeemedthemanagementofhyper-

glycemia in hopitalized patient in a non-critical

care etting a priority area in need of practice

guidelineandappointedaTakForcetoformulate

evidence-baed recommendation. The Tak Force

followedtheapproachrecommendedbytheGrading

of Recommendation, ement, evelopment,

and valuation (GR) group, an international

groupwithexpertieindevelopmentandimplemen-

tation of evidence-baed guideline(1). detailed

decriptionofthegradingchemehabeenpublihedelewhere(2).TheTakForceuedthebetavailable

reearchevidencetodevelopomeoftherecommen-

dation.TheTakForcealouedconitentlanguage

and graphical decription of both the trength of

a recommendation and the quality of evidence. n

termofthetrengthoftherecommendation,trong

recommendation ue the phrae we recommend

and the number 1, and weak recommendation

uethephraeweuggetandthenumber2. Cross-

filled circles indicatethequalityoftheevidence,uch

that denote very low quality evidence;

, lowquality; ,moderatequality;and

,highquality.TheTakForcehacondence

thatperonwhoreceivecareaccordingtothetrong

recommendationwillderive,onaverage,moregood

than harm. Weak recommendation require more

careful coniderationof the peron circumtance,

value,andpreferencetodeterminethebetcoure

of action. inked to each recommendation i a

decription of the evidence and the value that


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therapie. Thoe with BG meaure greater than

7.8 mmol/liter (140 mg/dl) require ongoing POC


(1| )

1.1.1.4. Evidence

n-hopital hyperglycemia i deneda anyglucoe

value greaterthan 7.8 mmol/liter(140 mg/dl)(20,

21).Hyperglycemiaoccurnotonlyinpatientwith

known diabete but alo in thoe with previouly

undiagnoeddiabeteandotherwithtrehyper-

glycemiathatmayoccurduringanacuteillneand

thatreolvebythetimeofdicharge(20,22,23).

Obervational tudie report that hyperglycemia i

preent in 32 to 38% of patient in community

hopital(6, 24), 41% ofcritically ill patient withacute coronary yndrome (13), 44% of patient

with heart failure (13), and 80% of patient after

cardiac urgery (25, 26). n thee report, approxi-

mately onethirdof non-intenive care unit (C)

patient and approximately 80% of C patient

hadnohitoryofdiabetebeforeadmiion(6,13,

2730).

The Clinical Practice Recommendation

endoretheinitiationofglucoemonitoringforboth

thoe with diabete and thoe without a knownhitory of diabete who are receiving therapie

aociatedwithhyperglycemia(31).Weagreewith

theerecommendationbutalouggetthatinitial

glucoe meaurement on admiion by the hopital

laboratoryiappropriateforallhopitalizedpatient,

irrepective of the preence of preexiting diabete

hitory or expoure to obviou hyperglycemia

inducer. The high prevalence of inpatient hyper-

glycemia with aociated poor outcome and the

opportunity todiagnoe newdiabete warrant thi

approach(6,24,32,33).Becauethedurationofcare

i frequently brief in the inpatient etting, the

aementofglycemiccontrolneedtobeperformed

earlyinthehopitalcoure.BedidePOCtetingha

advantage over laboratory venou glucoe teting.

POC teting at the point of care allow identi-

cationof patient who require initiation ormodi-

cationofaglycemicmanagementregimen(20,21).

POC monitoring ha been demontrated to be

eential in guiding inulin adminitration toward

organization of health care profeional involved

in inpatientdiabete care, includingthe merican

iabete ociation (), merican Heart

ociation, merican ociation of iabete

ducator (), uropean society of ndocri-

nology, and thesociety ofHopitalMedicine.The

central goal wa to provide practical, achievable,

and afe glycemic goal and to decribe protocol,

procedure, and ytem improvement needed to

facilitate their implementation. Thi document i

addreed to health care profeional, upporting

taff,hopitaladminitrator,andothertakeholder

focuedonimprovedmanagementofhyperglycemia

ininpatientetting.

1.0. AGNOSS AN

ECOGNTON O HPE-

GCEMA AN ABETES N

THE HOSPTA SETTNG

Recommendations

1.1. Werecommendthatclinicianaeallpatientadmitted to the hopital for a hitory of diabete.

Whenpreent,thidiagnoihouldbeclearlyidenti-

edinthemedicalrecord.(1| )

1.2. Weuggetthatallpatient,independentofa

priordiagnoiofdiabete,havelaboratoryBGteting

onadmiion.(2| )

1.3. We recommend that patient without a

hitoryofdiabetewithBGgreaterthan7.8mmol/

liter (140 mg/dl) be monitored with bedide POCteting for at leat 24 to 48 h. Thoe with BG

greater than 7.8 mmol/liter require ongoing POC


(1| )

1.4. We recommend that in previouly normo-

glycemicpatientreceivingtherapieaociatedwith

hyperglycemia,uchacorticoteroidoroctreotide,

andPbemonitoredwithbedidePOCteting

for at leat 24 to 48 h after initiation of thee


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diabete. Our recommendation reect conenu

opinionandthepracticalutilityofthitrategy.

Clinician mut keep in mind that an Hb1C

cutoffof6.5%identiefewercaeofundiagnoed

diabetethandoeahighfatingglucoe(38).several

epidemiological tudie have reported a low eni-

tivity(44to66%)butahighpecicity(76to99%)

for Hb1C greater than 6.5% in an outpatient

population (39, 40). mong hopitalized hypergly-

cemic patient, an Hb1C level above 6.0% wa

reported to be 100% pecic and 57% enitive

for the diagnoi of diabete, where a an Hb1C

below 5.2% effectively excluded a diagnoi of

diabete(41).

Glucoe and Hb1C value, together with themedical hitory, can be ued to tailor therapy and

ait in dicharge planning (42, 43). icharge

planning, education, and care tranition are

dicued in more detail in Section 4.4. Briey, the

dicharge plan optimally include the diagnoi of

diabete(ifpreent),recommendationforhort-and

long-term glucoe control, follow-up care, a lit of

educationalneed,andconiderationofappropriate

creening and treatment of diabete comorbiditie

(30,42,44).

There are limitationto the ue of anHb1C for

diagnoi of diabete in an inpatient population.

Thee include the relatively low diagnotic eni-

tivityandpotentialalteredvalueinthepreenceof

hemoglobinopathie(hemoglobinCorsCdieae),

high-doe alicylate, hemodialyi, blood tranfu-

ion, and iron deciency anemia (45). When

Hb1Ciuedforetablihingadiagnoiofdiabete,

analyihouldbeperformeduingamethodcertied

by the ational Glycohemoglobin standardization

Program (31), becauePOC Hb1C tetingi not

ufcientlyaccurateatthitimetobediagnotic.

achievingandmaintainingdeiredglycemicgoala

wellaforrecognizinghypoglycemicevent(16,21,

34,35).Motcurrentlyuedbedideglucoemeter,

althoughdeignedforcapillarywholebloodteting,

arecalibratedtoreportreultcompatibletoplama,

whichallowforreliablecompariontothelaboratory

glucoetet(16,22,36,37).

1.1.1.4. Values and preferences

Ourrecommendationreectconiderationoftheface

validityofolicitingandcommunicatingthediagnoi

ofdiabeteorhyperglycemiatomemberofthecare

team.Therik-to-benetofglucoetetinganddocu-

menting a hitory of diabete favor thi approach

depitethelackofrandomizedcontrolledtrial.

Recommendation

1.5. Werecommendthatallinpatientwithknown

diabeteorwithhyperglycemia(>7.8mmol/liter)be

aeedwithanHb1Clevelifthihanotbeen

performedinthepreceding23month.(1| )

1.5. Evidence

We upport the recommendation of uing a

laboratorymeaureofHb1Cbothforthediagnoi

ofdiabete andfor theidentication ofpatient at

rik for diabete (31). The recommendation

indicate that patient with an Hb1C of 6.5% or

higher can be identied a having diabete, and

patientwithanHb1Cbetween5.7and6.4%can

beconideredabeingatrikforthedevelopmentof

diabete(31).

MeaurementofanHb1Cduringperiodofhopi-

talization provide the opportunity to identify

patientwithknowndiabetewhowouldbenetfrom

intenication of their glycemic management

regimen.npatientwithnewlyrecognizedhypergly-

cemia, an Hb1C may help differentiate patient

with previouly undiagnoed diabete from thoe

with tre-induced hyperglycemia (32, 38). t i

importanttonotethattherearenorandomizedtrial

demontrating improved outcome uing Hb1C

leveltoaitinthediagnoiofdiabeteininpatient

withnewhyperglycemiaortoaitintailoringthe

glycemic management of inpatient with known


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Conitent ampling ite and method of

meaurementhouldbeuedbecaueglucoereult

can vary ignicantly when alternating between

nger-tickandalternativeite,orbetweenample

runinthelaboratoryvs.aPOCtetingdevice(53).

intheoutpatientetting,erroneoureultcanbe

obtainedfromnger-tickamplewhenevertheBG

irapidlyriingorfalling(53).

QualitycontrolprogramareeentialtomeetFood

andrugdminitration(F)requirementandto

maintaintheafety,accuracy,andreliabilityofBG

teting(21).TheFrequirethattheaccuracyof

glucoeanalyzerinthecentrallabbewithin10%of

the real value,whereaPOC meterare conidered

acceptable within 20% (21, 37); however, recent

reporthaveadvocatedimprovementortighteningofPOC meter accuracy tandard (37). ing meter

withbarcodingcapabilityhabeenhowntoreduce

data entry error inmedicalrecord (37).Capillary

BGvaluecanvarybetweenPOCmeter,epecially

athighorlowhemoglobinlevel,lowtiueperfuion,

and with ome extraneou ubtance (36, 53).

lthoughpatientcanbringtheirownglucoemeter

devicetothehopital,peronalmeterhouldnotbe

uedfordocumentationorfortreatmentofhypergly-

cemia.Hopitalmeterhouldfollowregulatoryand

licening quality control procedure to enure

accuracy and reliability of reult. Hopital ytem

withdatamanagementprogramcantranferreult

into electronic record to allow evaluation of

hopital-widepatternofglycemiccontrol(54).

Healthcareworkerhouldkeepinmindthatthe

accuracy of mot hand-held glucoe meter i far

fromoptimal(53).Therearepotentialinaccuracie

of POC teting including intrinic iue with the

technologyandvariabilitybetweendifferentlotoftet trip, inadequate ampling ite, varying

hemoglobin concentration, and other interfering

hematological factor in acutely ill patient (37,

55, 56). One tudy from the Center for ieae

Control (CC) of ve commonly ued glucoe

meter howed mean difference from a central

laboratorymethodtobeahigha32%andacoef-

cientofvariationof6to11%withaingletrained

medicaltechnologit(37).

2.0. MONTONG GCEMA N

THE NON-CTCA CAE SETTNG

Recommendations

2.1. WerecommendbedidecapillaryPOCteting

athepreferredmethodforguidingongoingglycemic

managementofindividualpatient.(1| )

2.2. We recommend the ue of BG monitoring

device that have demontrated accuracy of ue in

acutelyillpatient.(1| )

2.3. Werecommendthattimingofglucoemeaure

matchthepatientnutritionalintakeandmedicationregimen.(1| )

2.4. We ugget the following chedule for POC

teting: before meal and at bedtime in patient

who are eating, or every 46 h in patient who

are PO or receiving continuou enteral feeding.

(2| )

2.1.2.4. Evidence

MatchingthetimingofPOCtetingwithnutritional

intakeandthediabetemedicationregimeninthe

hopitalettingiconitentwithrecommendation

for the outpatient etting. POC teting i uually

performed four time daily: before meal and at

bedtimeforpatientwhoareeating(16,21).Premeal

POCtetinghouldbeobtainedacloetothetime

ofthemealtraydeliveryapoibleandnolonger

than1hbeforemeal(4648).Forpatientwhoare

PO or receiving continuou , POC teting i

recommended every 46 h. More frequent glucoe

monitoring i indicated in patient treated withcontinuou iv inulin infuion (49, 50) or after a

medicationchangethatcouldalterglycemiccontrol,

e.g. corticoteroid ue or abrupt dicontinuation of

orP(48,51,52),orinpatientwithfrequent

epiodeofhypoglycemia(16,28).

Capillary BG data facilitate the ability to adjut

inulintherapybaedinpartoncalculationoftotal

correction inulin doe over the preceding 24 h.


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11

RecenttudieuggetthatcontinuouBGmonitoring

device may be helpful in reducing incidence of

evere hypoglycemia in acute care (57, 58). More

tudie, however, are needed to determine the

accuracyandreliabilityofcontinuouBGmonitoring

deviceinhopitalizedpatient.lthoughpromiing,

continuouBGmonitoringhanotbeenadequately

tetedinacutecareandthereforecannotberecom-

mendedforhopitalizedpatientatthitime.

3.0. GCEMC TAGETS N THE

NON-CTCA CAE SETTNG

Recommendations

3.1. We recommend a premeal glucoe target of

lethan140mg/dl(7.8mmol/liter)andarandom

BGoflethan180mg/dl(10.0mmol/liter)forthe

majority of hopitalized patient with non-critical

illne.(1| )

3.2. We ugget that glycemic target be modied

accordingtoclinicaltatu.Forpatientwhoareable

to achieve and maintain glycemic control without

hypoglycemia,alowertargetrangemaybereaonable.

Forpatientwithterminalillneand/orwithlimited

life expectancy or at high rik for hypoglycemia, a

highertargetrange(BG


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ithe ability toreinforceeducation regarding meal

planningformanyperonwithdiabete.lthough

therearenorandomizedcontrolledtudiecomparing

different inpatient nutritional trategie, one tudy

conducted during a tranition from conitent

carbohydratetopatient-controlledmealplanfound

imilar glycemic meaure, with a trend toward le

hypoglycemia with a conitent carbohydrate plan

(16,61,68).

4.2. Transition from home to hospital

Recommendations

4.2.1. Werecommendinulintherapyathepreferred

methodforachievingglycemiccontrolinhopitalized

patientwithhyperglycemia.(1| )

4.2.2. We ugget the dicontinuation of oral

hypoglycemicagentandinitiationofinulintherapy

forthemajorityofpatientwithtype2diabeteat

thetime of hopital admiion for an acute illne.

(2| )

4.2.3. We uggetthatpatient treatedwithinulin

before admiion have their inulin doe modied

accordingtoclinicaltatuaawayofreducingthe

rikforhypoglycemiaandhyperglycemia.(2| )

4.2.1.4.2.3. Evidence

Patient with type 1 diabete have an abolute

requirement for inulin therapy and require treat-

ment with baal bolu inulin regimen to avoid

evere hyperglycemia and diabetic ketoacidoi.

Manypatientwithtype2diabetereceivinginulin

therapy a baal bolu or multiple daily injection

beforeadmiionareatrikforeverehyperglycemia

in the hopital if inulin therapy i dicontinued.ementoftheneedformodicationofthehome

inulin regimen i important becaue requirement

varyaccordingtoclinicaltreor,reaonforadmi-

ion,alteredcaloricintakeorphyicalactivity,and

changeinmedicalregimenthatcanaffectglycemic

level.Therearepatientwhorequirereductionin

inulindoetoavoidhypoglycemia,whereaother

requirehigherinulindoetoavoidortreatuncon-

trolledhyperglycemia(69).

beuefulincoordinatingdoeofrapid-actinginulin

tocarbohydrateingetion.(2| )

4.1.1.4.1.2. Evidence

MTianeentialcomponentofinpatientglycemic

managementprogram.MTidenedaaproceof nutritional aement and individualized meal

planning in conultation with a nutrition profe-

ional(31, 60). Thegoalof inpatientMTareto

optimizeglycemiccontrol,toprovideadequatecalo-

rie to meet metabolic demand, and to create a

dicharge plan for follow-up care (16, 6064).

lthoughthemajorityofnon-criticallyillhopital-

ized patient receive nutrition upport a three

dicretemealwithorwithoutchedulednackeach

day,omerequireorPupport(eesection5).

ackofattentiontoMTinthehopitalcontribute

tounfavorablechangeinBG(28,46,65).utrition

requirementoftendifferinthehomev.thehopital

etting.Thetypeoffoodmaychangeortherouteof

adminitration may differ, e.g. enteralor parenteral

feeding may be ued intead of olid food. utri-

tionalmanagementinthehopitalifurthercompli-

cated by hopital routine characterized by abrupt

dicontinuationofmealinpreparationfordiagnotic

tudie orprocedure, variability in appetite duetotheunderlyingillne,limitationinfoodelection,

and poor coordination between inulin admini-

tration and meal delivery that create difcultie

in predicting the efcacy of glycemic management

trategie(46).

conitent carbohydrate meal-planning ytem

mayhelptofacilitateglycemiccontrolinthehopital

etting (16, 46). The ytem i baed on the total

amount of carbohydrate offered rather than on

peciccaloriecontentateachmeal.Motpatient

receiveatotalof1,5002,000calorieperday,witha

rangeof1215carbohydrateerving.Themajority

ofcarbohydratefoodhouldbewholegrain,fruit,

vegetable,andlow-fatmilk,withretrictedamount

ofucroe-containingfood(66,67).nadvantage

totheueofconitentcarbohydratemealplani

that they facilitate matching the prandial inulin

doetotheamountofcarbohydrateconumed(16).

notheradvantageofaconitentcarbohydratediet


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Converiontobaalboluinulintherapybaedon

POC BG reult i both afe andefcaciou inthe

managementof hyperglycemic patient with type 2

diabete (33, 35, 69, 74). Patient with BG level

above 140 mg/dl (7.8 mmol/liter) who are eating

uual meal can have baal bolu inulin therapy

initiatedata totaldailydoebaedonbodyweight

(33,35,75).PatientwhoarePOcanreceivebaal

inulin alone with correction doe with a rapid-

actinganalogevery4horwithregularinulinevery

6 h (16, 33, 76, 77). n example of baal bolu

protocolandcorrectionaldoeprotocoliprovidedin

Table 1 (33, 35); however, many ucceful inulin

regimenhavebeenreportedintheliterature(16,28,

78,79).

The practice of dicontinuing diabete medicationand writing order for ss at the time of hopital

admiion reult in undeirable level of hypogly-

cemiaandhyperglycemia(8082).nonetudy(81),

therikforhyperglycemia(BG>11.1mmol/literor

200 mg/dl) increaed 3-fold in patient placed on

aggreiveliding-caleregimen.

4.2.1.4.2.3. Values and preferences

The recommendation to dicontinue agent other

thaninulinatthetimeofhopitalizationibaedinpartonthefactthatcontraindicationtotheueof

thee agent are preent in a high percentage of

patient on admiion or during hopitalization

(71,73).naddition,theueoforalagenttotreat

newlyrecognizedhyperglycemiacanreultindelay

inachievingdeiredglycemictarget,withthepoten-

tialtoadverelyaffectpatientoutcome.

4.2.1.4.2.3. Remarks

Hopitalareencouragedto:

Provide prompt to alert care provider that a

patient i receiving an oral antidiabetic agent

that may be contraindicated for ue in the

inpatientetting(e.g.ulfonylureaormetformin

in patient with renal inufciency or TZ in

patientwithheartfailure).

mplement educational order et that guide

appropriateueofcheduledinulintherapyin

thehopital(16,46,77,78,83).

Preadmiiondiabetetherapyinpatientwithtype2

diabete can include diet, oral agent, non-inulin

injectable medication, inulin, or combination of

theetherapie.Carefulaementoftheappropri-

atene of preadmiion diabete medication i

requiredatthetimeofhopitaladmiion.Theueof

oralandothernon-inulintherapiepreentunique

challengein thehopital ettingbecauethereare

frequent contraindication to their ue in many

inpatientituation(epi,POtatu,ivcontrat

dye, pancreatic diorder, renal failure, etc.) (21).

selectedpatientmaybecandidateforcontinuation

ofprevioulyprecribedoralhypoglycemictherapyin

thehopital.Patientcriteriaguidingthecontinued

ueoftheeagentincludethoewhoareclinically

table and eating regular meal and who have no

contraindicationtotheueoftheeagent.achofthe available clae of oral antidiabetic agent

poee characteritic that limittheir deirability

for inpatient ue. sulfonylurea are long-acting

inulin ecretagogue that can caue evere and

prolongedhypoglycemia,particularlyintheelderly,

inpatientwithimpairedrenalfunction,andinthoe

withpoornutritionalintake(70).Therearenodata

on hopital ue of the hort-acting inulin ecreta-

goguerepaglinideandnateglinide;however,therik

ofhypoglycemiaiimilartothatwithulfonylurea,uggeting the need for caution in the inpatient

etting.Metforminmutbedicontinuedinpatient

with decompenated congetive heart failure, renal

inufciency, hypoperfuion, or chronic pulmonary

dieae(71, 72) and in patient who are atrik of

developingrenalfailureandlacticacidoi,ucha

mayoccurwiththeadminitrationofivcontratdye

orurgery(73).Thiazolidinedione(TZ)cantake

everal week for thefullhypoglycemiceffect, thu

limitingtheuefulneoftheeagentforachieving

glycemic control in the hopital. Thee agent are

contraindicated in patient with congetive heart

failure, hemodynamic intability, or evidence of

hepaticdyfunction.ipeptidylpeptidaeVinhib-

itor delay the enzymatic inactivation of endoge-

nouly ecreted glucagon-like peptide-1, acting

primarilytoreducepotprandialglycemicexcurion.

Theeagentareleuefulinpatientwhoarenot

eatingorhavereducedoralintake.


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4.3.2.Weuggetthatprolongedueofsstherapy

beavoidedatheolemethodforglycemiccontrolin

hyperglycemic patient with hitory of diabete

duringhopitalization.(2| )

4.3.3. We recommend that cheduled c inulin

therapyconitofbaalorintermediate-actinginulin

4.3. Pharmacological therapy

Recommendations

4.3.1.Werecommendthatallpatientwithdiabete

treatedwithinulinathomebetreatedwithached-

uledcinulinregimeninthehopital.(1| )

TABLE 1. Example of a basal bolus insulin regimen for the management of non-critically ill patients with type 2 diabetes

A. Basalinsulinorders

Discontinueoraldiabetesdrugsandnon-insulininjectablediabetesmedicationsuponhospitaladmission.

Startinginsulin:calculatethetotaldailydoseasfollows:

0.2to0.3U/kgofbodyweightinpatients:aged70yrand/orglomerularltrationratelessthan60ml/min.

0.4U/kgofbodyweightperdayforpatientsnotmeetingthecriteriaabovewhohaveBGconcentrationsof7.811.1mmol/liter(140200mg/dl).

0.5U/kgofbodyweightperdayforpatientsnotmeetingthecriteriaabovewhenBGconcentrationis11.222.2mmol/liter(201400mg/dl).

Distributetotalcalculateddoseasapproximately50%basalinsulinand50%nutritionalinsulin.

Givebasalinsulinonce(glargine/detemir)ortwice(detemir/NPH)daily,atthesametimeeachday.

Giverapid-acting(prandial)insulininthreeequallydivideddosesbeforeeachmeal.Holdprandialinsulinifpatientisnotabletoeat.

Adjustinsulindose(s)accordingtotheresultsofbedsideBGmeasurements.

B. Supplemental(correction)rapid-actinginsulinanalogorregularinsulin

Supplementalinsulinorders.

Ifapatientisableandexpectedtoeatallormostofhis/hermeals,giveregularorrapid-actinginsulinbeforeeachmealandatbedtimefollowingtheusualcolumn (Section C below).

Ifapatientisnotabletoeat,giveregularinsulinevery6h(612612)orrapid-actinginsulinevery4to6hfollowingthesensitivecolumn (Section C below).

Supplementalinsulinadjustment.

Iffastingandpremealplasmaglucosearepersistentlyabove7.8mmol/liter(140mg/dl)intheabsenceofhypoglycemia,increaseinsulinscaleofinsulinfromtheinsulin-sensitivetotheusualorfromtheusualtotheinsulin-resistantcolumn.

Ifapatientdevelopshypoglycemia[BG141180 2 4 6 181220 4 6 8

221260 6 8 10

261300 8 10 12

301350 10 12 14

351400 12 14 16

>400 14 16 18

The numbers in each column of Section C indicate the number of units of regular or rapid-acting insulin analogs per dose. Supplemental dose is to beadded to the scheduled insulin dose. Give half of supplemental insulin dose at bedtime. If a patient is able and expected to eat all or most of his/her meals,supplemental insulin will be administered before each meal following the usual column dose. Start at insulin-sensitive column in patients who are not eating,elderly patients, and those with impaired renal function. Start at insulin-resistant column in patients receiving corticosteroids and those treated with more than80 U/d before admission. To convert mg/dl to mmol/liter, divide by 18. Adapted from Refs. 16, 35, and 69.


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10mmol/liter(180mg/dl)wererandomizedtoreceive

baalboluinulinwithglargineandgluliineinulin

orssalone.Thoeinthebaalbolugroupachieved

mean glucoe level of le than 10 mmol/liter

(180mg/dl)byday2andoflethan8.8mmol/liter

(160 mg/dl)by day4 with no increae in hypogly-

cemia (35). mong patient randomized to ss

alone,14%requiredrecuetherapywithbaalbolu

inulin dueto peritent BGabove13.3mmol/liter

(240mg/dl).econdmulticentertudycompared

two differentbaal bolu inulin regimen (detemir

pluapartv.PHpluregular)in130nonurgical

patient with type 2 diabete, of whom 56% were

receivinginulintherapybeforehopitalization(69).

There were no group difference in the level of

glycemic control achieved or in the frequency of

hypoglycemia,whichoccurredinapproximately30%of patient in each group. The majority of the

hypoglycemic event occurred in patient treated

withinulinbeforeadmiionwhowerecontinuedon

theameinulindoeatthetimeofrandomization,a

ndingthatemphaizetheimportanceoftherecom-

mendationtoevaluatethehomeinulinregimenat

thetimeofhopitalization.

4.3.1.4.3.4. Remarks

cheduled regimen of c baal bolu inulin i

recommended for mot patient with diabete in

non-Chopitaletting.uggetedmethodfor

determining tarting doe of cheduled inulin

therapyininulin-naivepatientinthehopitalcan

bebaedonapatientbodyweightandadminitered

aarangeof0.2to0.5/kgathetotaldailydoe

(Table1).Thetotaldailydoecanbedividedintoa

baal inulin component given once (glargine,

detemir)ortwice(PH,detemir)dailyandanutri-

tional or bolu component given before meal inpatientwhoareeatingorevery4to6hinpatient

oncontinuouorP.npatientwhoarePO

or unable to eat, bolu inulin mut be held until

nutrition i reumed; however, doe of correction

inulin can be continued to treat BG above the

deired range. djutment of cheduled baal and

boluinulincanbebaedontotaldoeofcorrection

inulin adminitered inthe previou 24h (35, 74).

When correction inulin i required before mot

givenonceortwiceadayincombinationwithrapid-

orhort-actinginulinadminiteredbeforemealin

patientwhoareeating.(1| )

4.3.4. Weuggetthatcorrectioninulinbeincluded

a a component of a cheduled inulin regimen

fortreatmentofBGvalueabovethedeiredtarget.

(2| )

4.3.1.4.3.4. Evidence

The preferred c inulin regimen for inpatient

glycemicmanagementincludetwodifferentinulin

preparation adminitered a baal bolu inulin

therapy,frequentlyincombinationwithacorrection

inulincale.Thebaalcomponentrequireadmini-

tration of an intermediate- or long-acting inulin

preparationonceortwiceaday.Theboluorpran-

dialcomponentrequiretheadminitrationofhort-

orrapid-actinginulinadminiteredincoordination

withmealornutrientdelivery(Table1).Correction

inulinrefertotheadminitrationofupplemental

doeofhort-orrapid-actinginulintogetherwith

theuualdoeofboluinulinforBGabovethetarget

range.Forpatientwhoarenoteating,baalinulini

continuedoncedaily(glargineordetemir)ortwice

daily[detemir/neutral protamine Hagedorn (PH)]

plucorrectiondoeofarapidinulinanalog(apart,lipro, gluliine) or regular inulin every 4- to 6-h

interval a needed. Correction-doe inulin hould

notbe confued with liding cale inulin,which

uuallyrefertoaetamountofinulinadminitered

forhyperglycemiawithoutregardtothetimingofthe

food,thepreenceorabenceofpreexitinginulin

adminitration, or even individualization of the

patientenitivitytoinulin.Correctioninulini

cutomizedtomatchtheinulinenitivityforeach

patient. Mot tandardized order et for c inulin

provide everal different correction-doe cale to

chooe from, depending on the patient weight or

totaldailyinulinrequirement.

Theafetyofcheduledbaalboluinulininpatient

witheithernewlyrecognizedhyperglycemiaortype2

diabete ha been demontrated in everal tudie

ofnoncriticallyillhopitalizedpatient(33,35,69,

74). n one tudy (35), 130 inulin-naive patient

with type 2 diabete who hadglucoe level above


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4.4. Transition from hospital to home

Recommendations

4.4.1. We ugget reintitution of preadmiion

inulin regimen or oral and non-inulin injectable

antidiabetic drug at dicharge for patient with

acceptable preadmiion glycemic control and

without a contraindication to their continued ue.

(2| )

4.4.2. Weuggetthatinitiationofinulinadmini-

trationbeintitutedatleatonedaybeforedicharge

toallowaementoftheefcacyandafetyofthi

tranition.(2| )

4.4.3. Werecommendthatpatientandtheirfamily

orcaregiver receive both written andoralintruc-tionregardingtheirglycemicmanagementregimen

atthetimeofhopitaldicharge.Theeintruction

needtobeclearlywritteninamannerthatiunder-

tandable to the peron who will adminiter thee

medication.(1| )

4.4.1.4.4.3. Evidence

Hopital dicharge repreent a critical time for

enuring a afe tranition to the outpatient etting

and reducing the need for emergency departmentviit and rehopitalization. Poor coordination of

patientcareatthetimeofpatienttranferbetween

ervice, tranfer to rehabilitation facilitie, or

dichargetohomeiaociatedwithmedicalerror

andreadmiion(88).

For patient dichargedhomeon inulin therapy a

a new medication, it i important that patient

education and written information be provided for

themethodandtimingofadminitrationofprecribed

doeandrecognitionandtreatmentofhypoglycemia(44).ngeneral,initiationofinulintherapyhould

be intituted at leat one day before dicharge to

allowaementoftheefcacyandafetyoftherapy.

nulinregimenareoftencomplex,uuallyentailing

the adminitration oftwodifferent inulin prepara-

tion that may require adjutment according to

home glucoe reading. Becaue hopital dicharge

can be treful to patient and their family,

orally communicated intruction alone are often

meal,itioftenthebaalinulinthatcanbetitrated

upward.WhenBGremainconitentlyelevatedat

onetimepoint,the doe ofboluinulinpreceding

that meaurement can be adjuted (78, 79). Many

patientrequiredailyinulinadjutmenttoachieve

glycemic control and to avoid hypoglycemia. The

hometotalbaalandprandialinulindoehouldbe

reducedonadmiioninpatientwithpoornutrition

intake,impairedkidneyfunction,orwithadmiion

BGlevellethan5.6mmol/liter(100mg/dl).

Thee recommendation apply for patient with

type1andtype2diabete;however,type1diabete

patient completely lack endogenou inulin

production. Type 1 diabete patient need to be

providedcontinuou,exogenoubaalinulin,even

whenfating,touppregluconeogeneiandketoneproduction.Failuretoprovidebaalinulintoatype

1diabetepatientcanleadtotherapiddevelopment

of evere hyperglycemia and diabetic ketoacidoi

(84,85).ngeneral,type1diabetepatienttypically

exhibit le inulin reitance and require lower

daily inulin doage than type 2 diabete patient,

epeciallyiftheyarenotobee.

Withincreaingutilizationofinulinpumptherapy,

manyintitutionallowpatientoninulinpumpto

continueuingtheedeviceinthehopital;other

expreconcernregardingueofadeviceunfamiliar

totaff,particularlyinpatientwhoarenotableto

managetheirownpumptherapy(86).Patientwho

uecontinuoucinulininfuionpumptherapyin

theoutpatientettingcanbecandidatefordiabete

elf-managementinthehopital,providedthatthey

havethementalandphyicalcapacitytodoo(20,

86,87).Theavailabilityofhopitalperonnelwith

expertieincontinuoucinulininfuiontherapyi

eential (16, 86, 87). t i important that nuringperonneldocumentbaalrateandboludoeona

regularbai(atleatdaily).Clearpolicieandproce-

durehouldbeetablihedattheintitutionallevel

toguidecontinuedueofthetechnologyintheacute

careetting.


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Hopital are encouraged to tandardize dicharge

intruction heet that provide information on

principaldiagnoi,keytetreultfromthehopital

tay, timing and adjuting of inulin doe, home

glucoe monitoring, and ign and ymptom of

hypoglycemiaandhyperglycemia.

5.0. SPECA STATONS

5.1. Transition from iv C to sc insulin therapy

Recommendations

5.1.1. Werecommendthatallpatientwithtype1andtype2 diabete betranitionedto cheduledc

inulintherapyatleat12hbeforedicontinuation

ofC.(1| )

5.1.2. We recommend that c inulin be admini-

tered before dicontinuation of C for patient

withoutahitoryofdiabetewhohavehyperglycemia

requiringmorethan2/h.(1| )

5.1.3. We recommend POC teting with daily

adjutmentoftheinulinregimenafterdicontinu-ationofC.(1| )

5.1.1.5.1.3. Evidence

patientrecoveringfromcriticalillnebeginto

eatregularmealoraretranferredtogeneralnuring

unit,theyrequiretranitionfromivtocinulinto

maintainreaonablelevelofglycemiccontrol(25,

51,90,91).Programthatincludetranitionproto-

colapartoftheirglycemicmanagementtrategyin

patientundergoingurgicalprocedurehavedemon-trated ignicant reduction in morbidity and

mortality,withlowercotandleneedfornuring

time(25,90).

several different protocol have been propoed to

guidethetranitionfromCtocinulin(43,88).

Themajority ofpatient without a prior hitory of

diabetereceivingCatarateof1/horleatthe

time of tranition may not require a cheduled c

inulin regimen (78, 83, 92,93). Many of thee

inadequate.Toaddrethiproblem,everalintitu-

tionhave etablihed formalized dicharge intruc-

tionforpatientwithdiabeteaawayofimproving

the clarity of intruction for inulin therapy and

glucoemonitoring(44,79,89).naddition,patient

a well a the provider adminitering pothopital

care hould be aware of the need for potential

adjutmentininulintherapythatmayaccompany

adjutment of other medication precribed at the

timeofhopitaldicharge(e.g.corticoteroidtherapy,

octreotide)(51).

Meaurement of Hb1C concentration during the

hopital tay can ait in tailoring the glycemic

management of diabetic patient at dicharge.

Patient with Hb1C below 7% can uually be

dicharged on their ame outpatient regimen (oralagentand/orinulintherapy)iftherearenocontra-

indication to therapy (i.e. TZ and heart failure;

metforminandrenalfailure).Patientwithelevated

Hb1C require intenication of the outpatient

antidiabeticregimen(oralagent,inulin,orcombi-

nationtherapy).Patientwithevereandymptomatic

hyperglycemia may benet from ongoing inulin

therapy(baalorbaalboluregimen).

4.4.1.4.4.3. Remarks

We ugget that the following component of

glycemic management be included a part of the

tranitionandhopitaldichargerecord:

principaldiagnoiorproblemlit;

Thereconciledmedicationlit,includinginulin

therapy;

Recommendationfortimingand frequency of

homeglucoemonitoring;

nformation regarding ign and ymptom of

hypoglycemia and hyperglycemia with intruc-

tionaboutwhattodoineachoftheecae;

formorlogbookforrecordingPOCmeaure

andlaboratoryBGreult;

lit of pending laboratory reult upon

dicharge;and

denticationofthehealthcareproviderwhoi

reponible for the ongoing diabete care and

glycemicmanagement.


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5.2. Patients receiving EN or PN

Recommendations

5.2.1.WerecommendthatPOCtetingbeinitiated

for patient with or without a hitory of diabete

receivingandP.(1| )


tinuedinpatientwithoutapriorhitoryofdiabete

ifBGvaluearelethan7.8mmol/liter(140mg/dl)

withoutinulintherapyfor2448hafterachievement

ofdeiredcaloricintake.(2| )

5.2.3. We ugget that cheduled inulin therapy

be initiated in patient with and without known

diabete who have hyperglycemia, dened a BG

greater than 7.8 mmol/liter (140 mg/dl), and whodemontrateaperitentrequirement( i.e.>12to24

h)forcorrectioninulin.(2| )

5.2.1.5.2.3. Evidence

Malnutritionireportedinupto40%ofcriticallyill

patient(65)andiaociatedwithincreaedrikof

hopitalcomplication,highermortalityrate,longer

hopital tay, and higherhopitalization cot(95).

mprovingthenutritionaltatemayretoreimmuno-

logical competence and reduce the frequency andeverity of infectiou complication in hopitalized

patient(9699).

There are everal retropective and propective

tudiedemontratingthattheueofandPi

an independent rik factor for the onet or aggra-

vation of hyperglycemia independent of a prior

hitoryofdiabete(65,100,101).Hyperglycemiain

thigroupofpatientiaociatedwithhigherrikof

cardiaccomplication,infection,epi,acuterenal

failure,anddeath(102104).nonetudy,atrong

correlationwareportedbetweenP-inducedhyper-

glycemiaandpoorclinicaloutcome.BGmeaureof

morethan150mg/dlbeforeandwithin24hofiniti-

ationofPwerepredictorofbothinpatientcompli-

cationandhopitalmortality(105).Together,thee

reultuggetthatearlyinterventiontopreventand

correcthyperglycemiamayimproveclinicaloutcome

inpatientreceivingandP.

patient can be treated with correction inulin to

determine whether they will require cheduled c

inulin.ncontrat,allpatientwithtype1diabete

andmotpatientwithtype2diabetetreatedwith

oral anti-diabetic agent or with inulin therapy

before admiion require tranition to c long- and

hort-actinginulinwithdicontinuationofC.

To preventrecurrence of hyperglycemia duringthe

tranitionperiodtocinulin,itiimportanttoallow

an overlap of 12 h between dicontinuation of iv

inulin and the adminitration of c inulin. Baal

inulinigivenbeforetranitionandcontinuedonce

(glargine/detemir) or twice (detemir/PH) daily.

Rapid-actinginulinanalogorregularinulinigiven

beforemealoracorrectiondoeinthepreenceof

hyperglycemia.

5.1.1.5.1.3. Remarks

n general, the initial doe and ditribution of c

inulin atthe time oftranition canbe determined

by extrapolating the iv inulin requirement over

thepreceding6to8htoa24-hperiod.dmini-

tering60to80%ofthetotaldailycalculateddoea

baalinulinhabeendemontratedtobebothafe

andefcaciouinurgicalpatient(16,90).ividing

the total daily doe a a combinationof baal andbolu inulin ha been demontrated to be afe in

medicallyillpatient(90,92,94).

t i important that conideration be given to a

patient nutritional tatu and medication, with

continuationofglucoemonitoringtoguideongoing

adjutment inthe inulin doe becauechange in

inulin enitivity can occur during acute illne.

Correction doe of rapid-acting analog or regular

inulincanbeadminiteredforBGvalueoutidethe

deired range. Hopital are encouraged to include

protocol that guide the tranition from C to c

inulin a a way of avoiding glycemic excurion

outidethetargetrange.Theueofprotocolhelp

reducerandompracticethatreultinhyperglycemia

orunwarrantedhypoglycemia.


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overtherapid-actinganaloginthigroupofpatient

becaue of the longer duration of action, requiring

fewerinjection(Table2).

For patient receiving P, regular inulin admini-

teredapartofthePformulationcanbebothafeand effective. subcutaneoucorrection-doe inulin

ioftenued,inadditiontotheinulinthatimixed

withthenutrition.WhentartingP,theinitialue

ofaeparateinulininfuioncanhelpinetimating

thetotaldailydoeofinulinthatwillberequired.

separateivinulininfuionmaybeneededtotreat

markedhyperglycemiaduringP.

5.3. Perioperative BG control

Recommendations

5.3.1.Werecommendthatallpatientwithtype1

diabetewhoundergominorormajorurgicalproce-

durereceiveeitherCorcbaalinulinwithbolu

inulinarequiredtopreventhyperglycemiaduring

theperioperativeperiod.(1| )

5.3.2. Werecommenddicontinuationoforaland

noninulin injectable antidiabetic agent before

Toaddrethiquetion,everalclinicaltrialhave

invetigatedtheueofdiabete-pecicformulaa

a way of ameliorating the rik for hyperglycemia

with . Thee diabete pecic formula differ

from tandard formulation by upplying a lower

percentage of total calorie a carbohydrate and

ubtitutingmonounaturatedfattyacidforamajor

component of adminitered fat calorie (106).n a

meta-analyi of tudie comparing thee with

tandard formulation, the potprandial rie in BG

wareducedby1.031.59mmol/liter(1829mg/dl)

(106). Thee reult ugget that the majority of

hyperglycemic patient will till require inulin

therapyforcontrolofhyperglycemiawhilereceiving

thitypeofnutritionalupport.

chieving deired glycemic goal in patientreceiving poe unique challenge (65, 74).

nanticipated dilodgement of feeding tube,

temporarydicontinuationofnutritionduetonauea,

formedicationadminitration(e.g. T4,phenytoin),or

for diagnotic teting, and cycling of with oral

intakein patient with an inconitent appetite all

poe clinical challenge to the precribing of

cheduled inulin therapy. n one tudy, patient

with peritent elevation in BG above 7.2 mmol/

liter (above 130 mg/dl) during therapy were

randomizedtoreceiveglargineoncedailyatatarting

doeof10,incombinationwithsswithregular

inulinadminiteredevery6h,orssalone.pprox-

imately50%ofpatientrandomizedtossrequired

recue therapy with PH to achieve a mean BG

below 10 mmol/liter (180 mg/dl) (74). The doe

of glargine inulin wa adjuted on a daily bai

accordingtoreultofPOCteting.fmorethanone

BGwaabove10mmol/literintheprior24h,the

doeofglarginewaincreaedbyapercentageofthe

totaldoeofcorrectioninulinadminiteredonthepreceding day. With ue of thi approach, a mean

glucoeofapproximately8.8mmol/liter(160mg/dl)

waachievedwithlowrikforhypoglycemia.

suggeted approache uing c inulin therapy in

patientreceivingcontinuou,cycled,orintermittent

therapyappearinTable2.Manymemberofthi

writingtakforcepreferfrequentinjectionofhort-

actingregularinulinorintermediate-actinginulin

Table 2. Approaches to insulin therapy during EN

ContinuousEN

Administerbasalinsulinonce(glargine,detemir)ortwice(detemir/NPH)adayincombinationwithashort-orrapid-actinginsulinanalogindivideddoses

every4h(lispro,aspart,glulisine)to6h(regularinsulin).Cycledfeeding

Administerbasalinsulin(glargine,detemir,orNPH)incombinationwithshort-orrapid-actinginsulinanalogatthetimeofinitiationofEN.

Repeatthedoseofrapid-actinginsulin(lispro,aspart,glulisine)at4-hintervalsorshort-acting(regular)insulinat6-hintervalsforthedurationoftheEN.Itispreferabletogivethelastdoseofrapid-actinginsulinapproximately4hbeforeandregularinsulin6hbeforediscontinuationoftheEN.

Bolusfeeding

Administershort-actingregularorrapid-actinginsulinanalog(lispro,aspart,glulisine)beforeeachbolusadministrationofEN.

Adapted from Refs. 16, 74, and 101.


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adminitering50%ofthebaalinulindoepreopera-

tively wa demontrated in one nonrandomized

qualityimprovementinitiative(114).dmiionBG

levelin584patientwithdiabetetreatedaccording

tothee recommendation rangedbetween 3.9 and

11.1mmol/liter(70200mg/dl)in77%ofpatient.

Hypoglycemia,denedaaBGoflethan3.9mmol/

liter,occurredinonly1.7%ofpatient.

Patient with type 2 diabete well-controlled by a

regimenofdietandphyicalactivitymayrequireno

pecial preoperative interventionfor diabete (111,

115). Glucoe level in thi group of patient can

oftenbecontrolledwithmalldoeofupplemental

hort-actinginulin.nulintreatedpatientorthoe

with poor metabolic control while onoral antidia-

beticagentwillrequireivinulininfuionorabaalbolucinulinregimentoachievethedeiredlevel

ofglycemiccontrol.

Patient with type 1 diabete undergoing minor or

majorurgicalprocedurerequireCorcbaalbolu

inulin adminitration adjuted according to the

reultofBGtetingtopreventthedevelopmentof

diabetic ketoacidoi (85, 116118). n one tudy,

BGvalueinagroupofubjectwithtype1diabete

whoreceivedtheirfulldoeofglargineinulinona

fatingdaywerecomparedwiththoeobtainedona

controldaywhentheparticipantwereeatingtheir

uualmeal(119).Therewerenoignicantdiffer-

ence in mean BG level between thee two day,

uggetingthatitiafetoadminiterthefulldoeof

baal inulin when a patient i made PO. For

patient with type 1 diabete whoe BG i well

controlled,mildreduction(between10and20%)in

thedoing ofbaal inulin areuggeted. For thoe

whoeBGiuncontrolled[i.e. BG>10mmol/liter

(200 mg/dl)], full doe of baal inulin can beadminitered.

Becaue the pharmacokinetic propertie of PH

inulindifferfromthoeofglargineanddetemir,doe

reduction of 2550% are uggeted, together with

theadminitration of hort-or rapid-acting inulin

forBG>8.3mmol/liter(150mg/dl)(Table3).

Prolongedueofssregimeninotrecommendedfor

glycemiccontrolduringthepotoperativeperiodin

urgery with initiation of inulin therapy in thoe

whodevelophyperglycemiaduringtheperioperative

periodforpatientwithdiabete.(1| )

5.3.3. When intituting c inulin therapy in the

poturgical etting, we recommend that baal (for

patientwhoarePO)orbaalbolu(forpatient

whoareeating)inulintherapybeintitutedathe

preferredapproach.(1| )

5.3.1.5.3.3. Evidence

There are everal cae-control tudie that demon-

trate an increaed rik for advere outcome in

patientundergoingelectivenoncardiacurgerywho

have either preoperative or potoperative hyper-

glycemia (19, 107110). Potoperative BG valuegreater than 11.1 mmol/liter (200 mg/dl) are

aociatedwithprolongedhopitallengthoftayand

an increaed rik of potoperative complication,

includingwoundinfectionandcardiacarrhythmia

(107110).nonetudy,theincidenceofpotoper-

ative infection in patient with glucoe level

above 12.2 mmol/liter (220 mg/dl) wa 2.7 time

higher than in thoe with glucoe level below

12.2 mmol/liter (109). n a recent report of 3,184

noncardiacgeneralurgerypatient,aperioperative

glucoevalueabove8.3mmol/liter(150mg/dl)wa

aociated with increaed length of tay, hopital

complication,andpotoperativemortality(107).

Perioperative treatment recommendation are

generallybaedonthetypeofdiabete,natureand

extentoftheurgicalprocedure,antecedentpharma-

cological therapy, and tate of metabolic control

beforeurgery(110,111).keyfactorfortheucce

of any regimen i frequent glucoe monitoring to

allowearlydetectionofanyalterationinmetabolic

control.

ll patient receiving inulin before admiion

requireinulinduringtheperioperativeperiod(112,

113). For mot patient, thi requirement include

adminitration of a percentage of the uual baal

inulin (PH, detemir, glargine) in combination

with correction doe of regular inulin or rapid-

actinginulinanalogforglucoelevelfrom8.3to

11.1 mmol/liter (150 to 200 mg/dl). The afety of


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5.4. Glucocorticoid-induced diabetes

Recommendations

5.4.1. We recommend that bedide POC teting

be initiated for patient with or without a hitory

of diabete receiving glucocorticoid therapy.

(1| )


tinuedin nondiabetic patient ifall BG reult are

below 7.8 mmol/liter (140 mg/dl) without inulin

therapyforaperiodofatleat2448h.(2| )

5.4.3. We recommend that inulin therapy be

initiated for patient with peritent hyperglycemia

whilereceivingglucocorticoidtherapy.(1| )

5.4.4. WeuggetCaanalternativetocinulin

therapy for patient with evere and peritent

elevationinBGdepiteueofcheduledbaalbolu

cinulin.(2| )

5.4.1.5.4.4. Evidence

Hyperglycemiaiacommoncomplicationofgluco-

corticoid therapy with a prevalence between 20

and50%amongpatientwithoutapreviouhitory

of diabete (51, 120, 121). Corticoteroid therapyincreaehepaticglucoeproduction,impairglucoe

uptakein peripheral tiue, and timulate protein

catabolimwithreultingincreaedconcentrationof

circulatingaminoacid,thuprovidingprecurorfor

gluconeogenei (122124). The oberved decreae

inglucoeuptakewithglucocorticoidtherapyeem

tobeamajorearlydefect,contributingtoincreaein

potprandial hyperglycemia. epite it frequency,

the impactof corticoteroid-induced hyperglycemia

onclinicaloutcomeuchamorbidityandmortality

inotknown.Fewtudiehaveexaminedhowbetto

treat glucocorticoid-induced hyperglycemia. n

general, dicontinuation of oral antidiabetic agent

with initiation of c baal bolu inulin therapy i

recommended for patient with glucocorticoid-

induced hyper-glycemia. The tarting inulin doe

and timing of inulin adminitration hould be

individualized depending on everity of hypergly-

cemia and duration and doage of teroid therapy.

For patient receiving high-doe glucocorticoid

hyperglycemicpatientwithdiabete.nonetudyof

211 general urgery patient with type 2 diabete

randomly aigned toreceive baal bolu inulin or

ss, glycemic control and patient outcome were

ignicantly better with the former (33). Patientwho were treated with ss hadhigher mean POC

glucoevalueandmorepotoperativecomplication

including wound infection, pneumonia, repiratory

failure, acute renal failure, and bacteremia. The

reult of that tudy indicate that treatment with

glargine once daily plu rapid-acting inulin before

mealimproveglycemiccontrolandreducehopital

complicationingeneralurgerypatientwithtype2

diabete(33).

5.3.1.5.3.3. Values and preferences

We place a high value on maintaining glycemic

controlevenforbriefperiodoftime,aoccurduring

period of fating for urgical or other procedure.

lthough avoidance of hypoglycemia i deired,

adminiteringapercentageoftheuualdoeoflong-

orintermediate-actinginulinappeartobeafeand

well tolerated,even for patient who arriveon the

morningoftheprocedure.

5.3.1.5.3.3. Remarks

Hopitalareencouragedto:

mplement protocol that guide afe glycemic

management of patient with hyperglycemia

duringandafterurgicalprocedure,and;

bandon practice that allow for random and

inconitent glycemic management in urgical

patient.

Table 3. Pharmacokinetics of sc insulin preparationsa

nsulin Onset Peak uration

Rapid-actinganalogs

515min 12h 46h

Regular 3060min 23h 610h

NPH 24h 410h 1218hGlargine 2h Nopeak 2024h

Detemir 2h Nopeak 1224h

a Renal failure leads to prolonged insulin action and alteredpharmacokinetics (162).


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6.1.6.3. Evidence

Hypoglycemia i dened a any glucoe level

below 3.9 mmol/liter (70 mg/dl) (127, 128). Thi

i thetandarddenition in outpatient andcorre-

late with the initial threhold for the releae of

counter-regulatory hormone (128, 129). severe

hypoglycemia ha been dened by many a le

than2.2mmol/liter(40mg/dl)(128),althoughthi

i lower than the approximately 2.8 mmol/liter

(50 mg/dl) level at which cognitive impairment

begininnormalindividual(129).

Thefearofhypoglycemiaiakeybarriertotheimple-

mentation of targeted glucoe control. lthough

notacommonahyperglycemia,hypoglycemiaia

well-recognized and feared complication in hopi-talizedpatientwithorwithoutetabliheddiabete

(130). The rik for hypoglycemia i higher during

periodofhopitalizationduetovariabilityininulin

enitivityrelatedtotheunderlyingillne,change

in counter-regulatory hormonal repone to proce-

dureorillne,andinterruptioninuualnutritional

intake(131,132).

Theprevalenceofhypoglycemiceventvarieacro

tudiedependingon thedenitionofhypoglycemia

and the pecic patient population evaluated. n a3-month propective review of conecutive medical

recordin2174hopitalizedpatientreceivingantidi-

abeticagent,206patient(9.5%)experiencedatotal

of484hypoglycemicepiode(133).largeglycemic

urveyexaminingreultofPOCbedideglucoetet

from126hopitalreportedaprevalenceofhypogly-

cemia(


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pecically at reducing hypoglycemia are lacking,

everal trategie appear reaonable. Thee include

ueofevidence-baedglucoecontrolprotocolwith

a demontrated afety record, etablihment of

hopital-wide policie that provide guidance on

identication of high-rik patient, and tandard-

izationofprocedurefordetectionandtreatmentof

hypoglycemia acro nuring unit (74, 143, 144).

Many patient require daily inulin adjutment to

avoidhypoglycemia(BG


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7.0. MPEMENTATON O A

GCEMC CONTO POGAM

N THE HOSPTA

Recommendations

7.1. Werecommendthathopitalprovideadmini-

trative upport for an interdiciplinary teering

committeetargetingaytemapproachtoimprove

careofinpatientwithhyperglycemiaanddiabete.

(1| )

7.2. Werecommendthateachintitutionetablih

a uniform method of collecting and evaluating

POC teting data and inulin ueinformation a a

way of monitoring the afety and efcacy of the

glycemiccontrolprogram.(1| )

7.3. We recommend that intitution provide

accurate device for glucoe meaurement at the

bedidewithongoingtaffcompetencyaement.

(1| )

7.1.7.3. Evidence

tiimportantformedicalcentertotargetimproved

careofinpatientwithhyperglycemiaand/ordiabete

by creating and upporting an interdiciplinary

teering committee with repreentation from key

group involved in thecare of thee patient (51).

Theteeringcommitteeideallywouldincluderepre-

entativefromphyiciangroup,nure,pharmacit,

cae manager, nutrition, information upport, and

qualityimprovementperonnelempoweredto:

eafetyandefcacyofproceeforglycemic

managementwithafocuonimprovingcareatthe identied area of deciency, within a

frameworkofqualityimprovement.

mplement trategie that guide taff and

phyician education with written policie,

protocol,andorderetwithintegrateddeciion

upportuingcomputerorderentry.

Conider ue of checklit, algorithm, and

tandardizedcommunicationforpatienttranfer

andhandoff.

appropriatetreatmentwithoutdelay,andretetBGat

precribedtimeintervalaftertreatment(148).For

theereaon,educationalinitiativeatthetimeof

protocolimplementationwithperiodicreinforcement

areeential(149).

Table 5. Suggested nurse-initiated strategies fortreating hypoglycemia

FortreatmentofBGbelow3.9mmol/liter(70mg/dl)inapatientwhoisalertandabletoeatanddrink,administer1520gofrapid-actingcarbohydratesuchas:a

one1530gtubeglucosegelor4(4g)glucosetabs(preferredforpatientswithendstagerenaldisease).

46ouncesorangeorapplejuice.

6ouncesregularsugarsweetenedsoda.

8ouncesskimmilk.

FortreatmentofBGbelow3.9mmol/liter(70mg/dl)inanalertandawakepatientwhoisNPOorunabletoswallow,administer20mldextrose50%solutioniv

andstartivdextrose5%inwaterat100ml/h.FortreatmentofBGbelow3.9mmol/literinapatientwithanalteredlevelofconsciousness,administer25mldextrose50%(1/2amp)andstartivdextrose5%inwaterat100ml/h.

Inapatientwithanalteredlevelofconsciousnessandnoavailableivaccess,giveglucagon1mgim.Limit,twotimes.

RecheckBGandrepeattreatmentevery15minuntilglucoselevelisatleast4.4mmol/liter(80mg/dl).

a Dose depends on severity of the hypoglycemic event.

Table 4. Key components of hypoglycemia preventionand management protocol

Hospital-widedenitionsforhypoglycemiaandseverehypoglycemia.

Guidanceondiscontinuationofsulfonylureatherapyandotheroralhypoglycemicmedicationsatthetimeofhospitaladmission.

Directionsforadjustmentsininsulindoseand/oradministrationofdextrose-containingivuidsforbothplannedandsuddenchangesinnutritionalintake.

Specicinstructionsforrecognitionofhypoglycemiasymptoms,treatment,andtimingforretestingdependingonglucoselevelsanddegreeofthepatientsneurologicalimpairmentandforretestingofglucoselevels.

Standardizedformfordocumentationandreportingofhypoglycemicevents,includingseverity,potentialcause(s),treatmentprovided,physiciannotication,andpatientoutcome.


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8.0. PATENT AN POESSONA

ECATON

Recommendations

8.1. We recommend diabete elf-management

education targeting hort-term goal that focu on

urvival kill: baic meal planning, medication

adminitration, BG monitoring, and hypoglycemia

andhyperglycemiadetection,treatment,andpreven-

tion.(1| )

8.2. We recommend identifying reource in the

community to which patient can be referred for

continuingdiabeteelf-managementeducationafterdicharge.(1| )

8.3. We recommend ongoing taff education to

updatediabeteknowledge, awella targeted taff

education whenever an advere event related to

diabetemanagementoccur.(1| )

8.1.8.3. Evidence

iabeteelf-managementeducationhatheability

to reduce length of hopital tay and improveoutcome after dicharge (16). n a meta-analyi

of 47 tudie on the effect of diabete education

on knowledge, elf-care, and metabolic control,

educational intervention were hown to increae

patientknowledgeandabilitytoperformelf-care

(156). The inpatient poition tatement

recommendinitiationofdiabeteelf-management

education early during the hopitalization to

allow time to addre potential decit in patient

knowledge(48).Withearlyintervention,thepatient

willhavemoreopportunitietopracticeandmater

urvival kill. Family member hould be included

whenever poible to upport and reinforce elf-

managementeducation(157,158).

n patient diabete educational goal hould focu

onthefollowingurvivalkill:baicmealplanning,

medication adminitration, POC teting, and

hypoglycemia detection, treatment, and prevention

(21,48).iabeteeducationimorecomplexinthe

Monitor the ue of order et and protocol,

intervening to reinforce protocol ue, and

reviing protocol a needed to improve

integration,clarity,andeaeofue.

ntitute continuing education program for

medical, nuring, and dietary taff to enhanceadherencetoprotocol.

The inpatient care of individual with diabete

and hyperglycemia i complex, involving multiple

providerwithvaryingdegreeofexpertiewhoare

diperedacromanydifferentareaofthehopital.

multidiciplinaryytemapproachcanhelpguide

meaningful progre away from clinical inertia and

toward afe glycemic control, hypoglycemia

prevention,andpatientpreparationforcaretrani-

tion(20,54,143,144,147).

The tranfer of patient between nuring unit of

clinicalcareteamiamajorcaueoferrorinthe

careofpatientwithhyperglycemiainthehopital.

Poor coordination of glucoe monitoring, meal

delivery, and inulin adminitration i a common

barriertooptimalcare(43,150,151).

vidence for the advantage of uing a ytem

approach come from everal ource: indutry and

highreliabilityorganization;endorementbymajor

profeional organization, baed on conenu

opinionandexperience(21,152);extrapolationof

experience applied to other dieae entitie (152);

and ucceful intitutionalglycemic control effort

viathiapproach(78,153155).

Reource outliningthe multidiciplinary approach,

protocol, and order et deign, implementation

trategie,andmethodformonitoringandcontinu-

ouly improving the proce are available in print

andinternetmedia(88).


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hyper-glycemia protocol, tracking of hypoglycemia

frequency and everity, providing diabete elf-

management education, and identication of a

program champion or team to pearhead glycemic

controlinitiative(160).

Theprincipleofdiabeteeducationandmanagement

inthehopitalapplyforpatientwithtype1andtype

2 diabete. ue to the lack endogenou inulin

production, patient with type 1 diabete require

exogenouinulintobeprovidedatalltimetoavoid

evere hyperglycemia and diabetic ketoacidoi (84,

85).naddition,patientwithtype1diabetearele

inulinreitantandaremorevulnerabletohypogly-

cemic event than thoe with type 2 diabete.

ttention to type of diabete, a well a to family

dynamicandpychologicalandemotionalmaturity,i eential in developing and implementing an

optimaldiabeteregimen.

hopitalettingbecauepatientareacutelyill,may

beexperiencingpain,andareundertre.Keeping

eionhortandfocuedwithminimalditraction

andinterruption contribute to a more productive

learningenvironment(48).

ocumentation ofteaching eion by health care

profeional promote communication of progre

to the next health care provider and ait in

dicharge planning. n ituation where failure to

performdiabeteelfcarepracticecontributedtothe

needforthehopitalization,educationcanbefocued

on the area of deciency a a way of preventing

readmiion(e.g.diabeticketoacidoi)(16,48,88).

Writtendichargeintructionondiabeteelf-care,

offered in the patient primary language wheneve

final standalone management of hyperglycemia guideline

Documents