In this post I link to and excerpt from the American Diabetes Association‘s Chapter 15 Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2021 [Full-Text HTML] [Full-Text PDF]. Diabetes Care 2021 Jan; 44(Supplement 1): S211-S220.
All that follows is from the above resource.
Hospital Care Delivery Standards
15.1 Perform an A1C test on all patients with diabetes or hyperglycemia (blood glucose >140 mg/dL [7.8 mmol/L]) admitted to the hospital if not performed in the prior 3 months. B
15.2 Insulin should be administered using validated written or computerized protocols that allow for predefined adjustments in the insulin dosage based on glycemic fluctuations.
Considerations on Admission
High-quality hospital care for diabetes requires standards for care delivery, which are best implemented using structured order sets, and quality assurance for process improvement.
Initial orders should state the type of diabetes (i.e., type 1, type 2, gestational diabetes mellitus, pancreatic diabetes) when it is known. Because inpatient treatment and discharge planning are more effective if based on preadmission glycemia, an A1C should be measured for all patients with diabetes or hyperglycemia admitted to the hospital if the test has not been performed in the previous 3 months (6–9).
Thus, where feasible, there should be structured order sets that provide computerized advice for glucose control. Electronic insulin order templates also improve mean glucose levels without increasing hypoglycemia in patients with type 2 diabetes, so structured insulin order sets should be incorporated into the CPOE (16,17).
Diabetes Care Providers in the Hospital
15.3 When caring for hospitalized patients with diabetes, consult with a specialized diabetes or glucose management team when possible. C
In a cross-sectional comparison of usual care to management by specialists who reviewed cases and made recommendations solely through the electronic medical record, rates of both hyper- and hypoglycemia were reduced 30–40% by electronic “virtual care” (22). Details of team formation are available in The Joint Commission Standards for programs and from the Society of Hospital Medicine (23,24).
Even the best orders may not be carried out in a way that improves quality, nor are they automatically updated when new evidence arises. To this end, the Joint Commission has an accreditation program for the hospital care of diabetes (23), and the Society of Hospital Medicine has a workbook for program development (24).
Glycemic Targets In Hospitalized Patients
15.4 Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold ≥180 mg/dL (10.0 mmol/L). Once insulin therapy is started, a target glucose range of 140–180 mg/dL (7.8–10.0 mmol/L) is recommended for the majority of critically ill and noncritically ill patients. A
15.5 More stringent goals, such as 110–140 mg/dL (6.1–7.8 mmol/L), may be appropriate for selected patients if they can be achieved without significant hypoglycemia. C
Hyperglycemia in hospitalized patients is defined as blood glucose levels >140 mg/dL (7.8 mmol/L) (2,3,25). Blood glucose levels persistently above this level should prompt conservative interventions, such as alterations in diet or changes to medications that cause hyperglycemia.
Hypoglycemia in hospitalized patients is categorized by blood glucose concentration and clinical correlates (Table 6.4) (26): Level 1 hypoglycemia is a glucose concentration 54–70 mg/dL (3.0–3.9 mmol/L). Level 2 hypoglycemia is a blood glucose concentration <54 mg/dL (3.0 mmol/L), which is typically the threshold for neuroglycopenic symptoms. Level 3 hypoglycemia is a clinical event characterized by altered mental and/or physical functioning that requires assistance from another person for recovery. Levels 2 and 3 require immediate correction of low blood glucose.
Based on these results [see article for details], insulin therapy should be initiated for treatment of persistent hyperglycemia ≥180 mg/dL (10.0 mmol/L) and targeted to a glucose range of 140–180 mg/dL (7.8–10.0 mmol/L) for the majority of critically ill patients. Although not as well supported by data from randomized controlled trials, these recommendations have been extended to hospitalized patients without critical illness.