Lippincott Nursing Pocket Card - Updated Nov. 2020

Managing Diabetes in the Hospital Setting

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Managing Diabetes in the Hospital Setting

It is critical for healthcare providers to effectively manage their patients’ diabetes to prevent complications from hypoglycemia and hyperglycemia which can result in increased morbidity, mortality, hospital admissions, and length of stay. A brief review of diabetes mellitus classification and diagnosis is provided followed by recommendations for management in the hospital setting.

Classification & Clinical Findings (American Diabetes Association, 2019)

  • Type 1 diabetes – deficiency of insulin secretion due to autoimmune β-cell destruction that leads to absolute insulin deficiency
    • Diagnosis is based on the classic 3 P’s (polyuria, polyphagia, polydipsia) plus two of the following lab results gathered from the same blood sample:
      • A1C level of 6.5% or higher
      • Fasting plasma glucose (FPG) > 126 mg/dL
      • Random blood glucose level > 200 mg/dL
  • Type 2 diabetes – progressive loss of β-cell insulin secretion often with concurrent insulin resistance
    • Diagnosis is indicated by two of the following lab results gathered from the same sample:
      • A1C level of 6.5% or higher
      • Fasting plasma glucose (FPG) > 12g mg/dL
      • Random blood glucose level > 200 mg/dL
  • Gestational diabetes mellitus (GDM) – diabetes in pregnancy, usually diagnosed in the second or third trimester when overt diabetes was not present prior to pregnancy; characterized by glucose intolerance related to insulin resistance
  • Prediabetes
    • Glucose levels do not fall in diabetic range but are too high to be considered normal. Prediabetes is diagnosed by the presence of impaired fasting glucose (IFG), impaired glucose tolerance (IGT), and/or an A1C level of 5.7% to 6.4%.
    • Testing should be performed in asymptomatic overweight or obese (body mass index [BMI] ≥ 25 kg/m2 or ≥ 23 kg/m2 for Asian Americans) individuals with any of the following risk factors:
      • Race at high risk for developing diabetes (Black, Native American, Latino, Pacific Islander, Asian American)
      • First-degree relative with diabetes
      • History of cardiovascular disease (CVD)
      • Hypertension (blood pressure ≥ 149/90 mmHg, or currently receiving hypertensive therapy)
      • High-density lipoprotein (HDL) cholesterol < 35 mg/dL and/or triglycerides > 250 mg/dL
      • Women with polycystic ovarian syndrome (PCOS)
      • Physical inactivity
  • Specific types of diabetes
    • Monogenic diabetes syndromes (neonatal diabetes and maturity-onset diabetes of the young [MODY])
    • Diseases of exocrine pancreas (cystic fibrosis [CF] and pancreatitis)
    • Drug- or chemically-induced diabetes related to glucocorticoid use, treatment for human immunodeficiency virus/acquired immunodeficiency syndrome [HIV/AIDS], or posttransplant related treatment.

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Recommendations for Care

General Recommendations (American Diabetes Association, 2018)

  • Document type of diabetes (type 1 or type 2) or “no history of diabetes” in the medical record.
  • Check A1C levels in all patients with diabetes or hyperglycemia (blood glucose > 140 mg/dL) admitted to the hospital if no result has been documented in the prior 3 months. An A1C value ≥ 6.5% (48 mmol/mol) on admission suggests that diabetes preceded hospitalization.
  • Assess diabetes self-management knowledge on admission and provide diabetes self- management education (DSME) as appropriate.
  • A validated written or computerized protocol in place that allows for predefined adjustments in insulin dosing based on glycemic fluctuations is recommended.
  • Monitor glucose in non-diabetic patients at high-risk for hyperglycemia, such as those:
    • Receiving enteral or parental nutrition
    • Prescribed glucocorticoids, octreotide or immunosuppressive medications
  • Insulin therapy and blood glucose targets should be individualized for critically ill and noncritically ill patients.
  • The preferred treatment for hospitalized noncritically ill patients with poor oral intake or taking nothing by mouth (NPO) is basal insulin or basal insulin with bolus correction. For those with adequate oral intake, basal, prandial, and correction insulin is preferred.
  • The adoption and implementation of a hypoglycemia management protocol is recommended.
Insulin
Follow your institution policies and written orders for insulin administration.
General guidelines (American Diabetes Association, 2018):
  • Monitor glucose before meals and at bedtime per orders.
  • If a patient is not eating, or is NPO, monitor glucose every 4 to 6 hours and treat per orders.
  • Subcutaneous rapid- or short-acting insulin injections are recommended.
  • Administer insulin for persistent hyperglycemia ≥ 180 mg/dL (10.0 mmol/L).
  • Target glucose range to 140-180 mg/dL (7.8- 10.0 mmol/L) for the majority of critically ill patients and noncritically ill patients.
  • Tighter glucose control < 140 mg/dL (< 7.8 mmol/L) may be used for some patients if it does not cause significant hypoglycemia.
  • Higher glucose levels may be acceptable in terminally ill patients, in patients with severe comorbidities, and in patient care settings where frequent monitoring is not possible.
  • Use clinical judgment and ongoing assessment of the patient’s clinical status, including changes in glucose levels and concomitant medications that may affect glucose levels (i.e. glucocorticoids).
  • Important reminders:
    • Significant discrepancies among capillary, venous, and arterial plasma blood glucose samples may occur with low or high hemoglobin concentrations or hypoperfusion.
    • Point-of-care (POC) meters may have a +/- 20% error rate. Glucose results that do not correlate with the patient’s clinical status should be confirmed with a conventional lab-tested glucose sample.
    • Prohibit sharing of finger-stick lancing devices, needles, and meters to reduce the risk of transmission of blood-borne disease. Insulin pens are “for single patient use only.”
    • The following are NOT recommended in the hospital setting (American Diabetes Association, 2018):
      • Sole use of sliding scale insulin
      • Premixed insulin regimens
      • Continuous glucose monitoring
Insulin Dose
  • If the patient was previously on insulin, the preadmission dose should be used as a starting point.
    • Typically based on weight and range from 0.4 to 1.0 units/kg/day
  • For non-critically ill patients with good nutritional intake, insulin therapy should include:
    • Basal insulin (long-acting dose): defined as the amount of insulin secreted throughout the day in someone without diabetes; helps control blood glucose between meals and during sleep
    • Bolus/nutritional insulin (meal-time): calculated based on carbohydrate (grams) intake
    • Correctional (supplemental) insulin for hyperglycemia above the target as needed and prescribed
  • For non-critically ill patients with poor oral intake or taking nothing by mouth (NPO), the recommendation is use of basal insulin or basal plus bolus correctional insulin regimen. Administer rapid-acting insulin immediately after the patient eats or calculate the carbohydrates consumed and cover accordingly.
  • For patients with type 1 diabetes, it is not recommended to dose insulin based on premeal glucose level alone as this does not account for basal insulin requirements or caloric intake and may lead to hypoglycemia, hyperglycemia, and diabetic ketoacidosis (DKA).
For patients receiving enteral or parenteral feedings, please refer to the guidelines  outlined by the American Diabetes Association (2018). Insulin degludec has been added as a basal insulin option for enteral/parenteral feedings.

Hyperglycemia & Hypoglycemia

Please refer to the Nursing Pocket Card Managing Acute Diabetic Complications.

Hyperglycemia (Lippincott Procedures, 2020)

  • In hospitalized patients, hyperglycemia is defined as blood glucose > 140 mg/dL (7.8 mmol/L).
  • Signs and symptoms include increased thirst, increased urination, weight loss, headache, decreased energy level and blurry vision.
  • Causes (other than diabetes) include stress from infection, acute illness, or surgery.
  • Treat with correctional insulin as needed and prescribed.

Hypoglycemia (Lippincott Procedures, 2020)

  • A blood glucose level less than 70 mg/dL (3.9 mmol/L) is considered hypoglycemia in patients with diabetes.
  • Early symptoms include shakiness, weakness, sweatiness, hunger, dizziness, light-headedness, palpitations, and anxiety.
  • Central nervous system signs and symptoms include vision changes, gait disturbances, changes in affect or behavior, confusion, paresthesia, slurred speech and sleepiness progressing to coma or seizure.

Considerations for Special Settings (American Diabetes Association, 2018)

Critical Care

  • Utilize a continuous intravenous (IV) insulin infusion for blood glucose ≥ 180 mg/dL (10.0 mmol/L).
  • Titrate infusion carefully to prevent hypoglycemia, per orders.
  • Monitor blood glucose every 30 minutes to 2 hours while on a continuous IV insulin infusion, per orders.
  • A validated written or computerized protocol that allows for titration of the infusion rate based on glycemic fluctuations and insulin dose is recommended.
  • Regular or rapid-acting subcutaneous insulin should be given 1 hour before the infusion is stopped OR intermediate or long-acting subcutaneous insulin should be given 2-4 hours before the infusion is stopped.
  • Failure to overlap the IV and subcutaneous insulin may result in rapid hyperglycemia and risk of diabetic ketoacidosis (DKA) in patients with type 1 diabetes.

Perioperative Care

  • Recommended target glucose is 80-180 mg/dL (4.4-10.0 mmol/L).
  • Perform a preoperative risk assessment for patients at high risk for ischemic heart disease and those with autonomic neuropathy or renal failure.
  • Hold metformin the day of surgery.
  • Hold other oral hypoglycemic agents the morning of surgery and give half the NPH dose or 60-80% of the dose of long-acting analog or pump basal insulin.
  • Monitor blood glucose every 4-6 hours while NPO and treat with short-acting insulin as needed.
  • In non-cardiac general surgery patients, basal insulin plus premeal regular or short-acting insulin (basal-bolus) coverage is associated with improved glycemic control and lower rates of perioperative complications compared with sliding scale regimens.

Patient Self-Management (American Diabetes Association, 2018)

  • Patients may self-manage their diabetes in the hospital if the patient has:
    • A history of successful self-management of diabetes at home
    • Demonstrated the cognitive and physical skills needed to self-administer insulin and perform self-monitoring of blood glucose
    • Adequate oral intake
    • Shown proficiency in carbohydrate estimation
    • Been utilizing multiple daily insulin injections or continuous subcutaneous insulin infusion (CSII) pump therapy
    • Stable insulin requirements
    • An understanding of sick-day management
  • If self-management is used, a hospital protocol is recommended requiring that the patient, nursing staff, and provider agree that self-management is appropriate.

Continuous Subcutaneous Insulin Infusion (CSII)

Patients with continuous subcutaneous insulin infusion pumps may continue to self-manage their infusion if they are mentally and physically capable to do so.
  • Confirm that the patient has the supplies required to safely manage the pump.
  • Having a policy and procedure in place to help guide inpatient CSII therapy is recommended.
  • Document basal and bolus doses at least daily.
  • If the pump is discontinued for procedures, diagnostic imaging or surgery, subcutaneous insulin should be prescribed.

Discharge Planning (American Diabetes Association, 2018)

Please refer to the Nursing Pocket Card Discharge Planning for Patients with Diabetes Mellitus.
 

References:

American Diabetes Association. (2019). Standards of medical care in diabetes. Diabetes Care, 42(Suppl. 1), S1–S183. Accessed March 2020 via the Web at https://care.diabetesjournals.org/content/42/Supplement_1/S4
 
American Diabetes Association. (2018). Standards of Medical Care in Diabetes–2018. Diabetes Care: The Journal of Clinical and Applied Research and Education, 41(1), S1-S151.
 
Lippincott Procedures (2020). Blood glucose monitoring. Retrieved from https://procedures.lww.com/lnp/view.do?pId=858347&hits=hypoglycemia&a=true&ad=false