Diabetes Care in the Hospital
Based on guidelines from the American Diabetes Association.
Standards of Medical Care
Hospital Care Delivery Standards
Perform an A1C 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.
Level 2
Physician Order Entry
Insulin should be administered using validated written or computerized protocols that allow for predefined adjustments in the insulin dosage based on glycemic fluctuations.
Clinical principle
Diabetes Care Providers in the Hospital
When caring for hospitalized patients with diabetes, consider consulting with a specialized diabetes or glucose management team where possible.
Clinical principle
Glycemic Targets in Hospitalized Patients
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 patients and noncritically ill patients.
Level 1
More stringent goals, such as 110–140 mg/dL (6.1–7.8 mmol/L), may be appropriate for selected patients, if this can be achieved without significant hypoglycemia.
Level 3
Antihyperglycemic Agents in Hospitalized Patients
Basal insulin or a basal plus bolus correction insulin regimen is the preferred treatment for noncritically ill hospitalized patients with poor oral intake or those who are taking nothing by mouth. An insulin regimen with basal, prandial, and correction components is the preferred treatment for noncritically ill hospitalized patients with good nutritional intake.
Level 1
Sole use of sliding scale insulin in the inpatient hospital setting is strongly discouraged.
Level 1
Hypoglycemia
A hypoglycemia management protocol should be adopted and implemented by each hospital or hospital system. A plan for preventing and treating hypoglycemia should be established for each patient. Episodes of hypoglycemia in the hospital should be documented in the medical record and tracked.
Clinical principle
The treatment regimen should be reviewed and changed as necessary to prevent further hypoglycemia when a blood glucose value of <70 mg/dL (3.9 mmol/L) is documented.
Level 3
Transition from the Acute Care Setting
There should be a structured discharge plan tailored to the individual patient with diabetes.
Level 2
What do the icons mean?
How much evidence supports it?
Level 1
Clear evidence from well-conducted, generalizable randomized controlled trials that are adequately powered, including evidence from a well-conducted multicenter trial or evidence from a meta-analysis that incorporated quality ratings in the analysis; compelling nonexperimental evidence, i.e., “all or none” rule developed by the Centre for Evidence-Based Medicine at the University of Oxford; supportive evidence from well-conducted randomized controlled trials that are adequately powered, including evidence from a well-conducted trial at one or more institutions or evidence from a meta-analysis that incorporated quality ratings in the analysis.Level 2
Supportive evidence from well-conducted cohort studies: evidence from a well-conducted prospective cohort study or registry or evidence from a well-conducted meta-analysis of cohort studies; supportive evidence from a well-conducted case-control study.Level 3
Supportive evidence from poorly controlled or uncontrolled studies: evidence from randomized clinical trials with one or more major or three or more minor methodological flaws that could invalidate the results or evidence from observational studies with high potential for bias (such as case series with comparison with historical controls); evidence from case series or case reports; conflicting evidence with the weight of evidence supporting the recommendation.Clinical principle
Expert consensus or clinical experience.
