Patients with diabetes mellitus account for 22% of all hospital inpatient days. Not only are these patients more likely to be hospitalized, but they also have longer hospital stays than patients without diabetes and their inpatient care amounts to half of the $174 billion total medical expenditures for diabetes in the United States. As the worldwide epidemic of type 2 diabetes mellitus grows, so does the need for inpatient glycemic control.
In recognition of the need for glycemic control, the American Association of Clinical Endocrinologists and the American Diabetes Association developed a consensus statement on inpatient glycemic management. The statement’s main goals are to “identify reasonable, achievable, and safe glycemic targets and to describe the protocols, procedures, and system improvements needed to facilitate their implementation.” To help you and your colleagues align your practice with current guidelines, the following list summarizes the statement’s recommendations.
Critically ill patients
- Initiate insulin therapy to treat persistent hyperglycemia, starting at 180 mg/dL or less.
- After insulin therapy begins, maintain the blood glucose level at 140 to 180 mg/dL for most critically ill patients.
- Administer insulin by IV infusion to achieve and maintain glycemic control.
- Adhere to insulin infusion protocols that have proven safety and efficacy and low rates of hypoglycemia.
- During IV insulin therapy, frequently monitor the blood glucose level to help prevent hypoglycemia and achieve optimal glucose control.
Noncritically ill patients
- For most patients receiving insulin, expect to use a premeal blood glucose target of less than 140 mg/dL and a random blood glucose target of less than 180 mg/dL, if these targets can be achieved safely.
- Expect to use more stringent targets for stable patients and less stringent targets for terminally ill patients or those with severe comorbidities.
- Administer insulin by subcutaneous injection (the preferred method for achieving and maintaining optimal blood glucose control), when appropriate for the patient’s needs.
- Avoid prolonged therapy with sliding scale insulin as the sole regimen.
- Avoid noninsulin antihyperglycemic agents for most hospitalized patients who need hyperglycemia treatment.
- Use clinical judgment and ongoing patient assessments when making day-to-day decisions about hyperglycemia treatment.
- Avoid overtreatment and undertreatment of hyperglycemia.
- Educate hospital staff so they can optimally care for inpatients with hyperglycemia.
- In patients with anemia, polycythemia, hypoperfusion, or certain medication regimens, cautiously interpret the results of point-of-care glucose meters.
- Promote a rational systems approach to inpatient glycemic management by gaining the buy-in and financial support of hospital administrators.
Discharge planning and other issues
- Begin planning for transition to the outpatient setting at the time of hospital admission.
- Engage in discharge planning, patient education, and clear communication with outpatient providers to ensure a successful transition.
- Know that successful glycemic control in hospitalized patients leads to cost-effective hyperglycemia care management.
- Encourage continued research into inpatient hyperglycemia management in hospital settings.