Glucose Testing Suggested for All Inpatients

All patients admitted to the hospital in noncritical care settings should have their blood glucose tested, according to a new clinical practice guideline from the Endocrine Society.

Unlike previous guidelines based largely on data from intensive care and critical care settings, the new guideline focuses on glucose management in noncritical settings, with special emphasis on systemic issues such as patient transition between hospital units and from inpatient to outpatient settings. The guidelines also include detailed guidance for creating systems and protocols to ensure optimal patient management and safety (Diabetes Care [2009;32:1119-31]).

"Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Setting: An Endocrine Society Clinical Practice Guideline" was developed by an eight-member panel with representatives from the American Diabetes Association, American Heart Association, American Association of Diabetes Educators, European Society of Endocrinology, and the Society of Hospital Medicine. The lead author was Dr. Guillermo E. Umpierrez, professor of medicine at Emory University, and chief of diabetes and endocrinology at Grady Memorial Hospital, both in Atlanta.

The guideline has eight sections, all focused on the noncritical hospital setting: diagnosis and recognition of hyperglycemia and diabetes, monitoring glycemia, glycemic targets, management of hyperglycemia, special situations, recognition and management of hypoglycemia, implementation of a glycemic control program, and patient and professional education.

The panel’s advice was characterized as "recommended" for items with strong evidence and "suggested" for items with less evidence. In the first of the guideline’s eight sections, the panel recommended all patients be assessed on admission for a history of diabetes and suggested laboratory blood glucose testing on admission for all patients, regardless of prior diagnosis of diabetes.

"There’s abundant data to show that a very large number of people … [are admitted] with undiagnosed diabetes and people also develop stress hyperglycemia" and both conditions affect patient outcomes, Dr. Richard Hellman said in an interview. Dr. Hellman is a coauthor of the guidelines and an endocrinologist who is a clinical professor of medicine at the University of Missouri–Kansas City.

<[stk -3]>While the accuracy of point-of-care testing is not optimal, the panel recommended bedside glucose testing of capillary blood because of the need to time glucose measures to the patient’s nutritional intake and medication regimens. Personal glucose meters should not be used, and continuous glucose monitors while "promising," have not been adequately tested in acute care and therefore can’t be recommended for hospital use at this time, Dr. Umpierrez and his associates wrote.<[etk]>

As in the 2009 guideline that addressed critical care patients, the glycemic targets are less than 140 mg/dL premeal and less than 180 mg/dL random for the majority of hospitalized patients with noncritical illness. Lower targets might be considered among patients who are able to achieve them without hypoglycemia, while higher targets might be appropriate for those at high risk for hypoglycemia and those with a limited life expectancy.

Medical nutrition therapy is recommended as a component of the glycemic management program for all hospitalized patients with diabetes and hyperglycemia. Meals with consistent amounts of carbohydrate are suggested to help coordinate dosing of rapid-acting insulin.

Insulin therapy is the preferred method for achieving glycemic control in all hospitalized patients with diabetes and hyperglycemia, the panel said. At admission, they suggested, oral hypoglycemic agents should be discontinued and insulin therapy should be initiated in acutely ill patients with type 2 diabetes. Oral agents are contraindicated in hospitalized patients with decompensated heart failure, renal insufficiency, hypoperfusion, or chronic pulmonary disease, and in any patient given intravenous contrast dye, the authors noted.

<[stk -3]>For patients who are eating, the panel recommended scheduled subcutaneous basal or intermediate-acting insulin once or twice daily in combination with rapid- or short-acting insulin administered before meals. <[etk]>

Prolonged use of sliding-scale therapy should be avoided as the sole method for glycemic control, the panel wrote.

"There’s abundant data to show that a very large number of people [are admitted] with undiagnosed diabetes and people also develop stress hyperglycemia."

<[stk -3]>Two recent studies led by Dr. Umpierrez show basal-bolus insulin regimens to be superior to sliding scale insulin treatment. One of those studies was done in noncritically ill hospitalized patients with type 2 diabetes (Diabetes Care 2007;30:2181-6), and the other was done in type 2 patients undergoing general surgery (Diabetes Care 2011;34:256-61). <[etk]>

Diabetes self-management education is recommended for patients, including both short-term "survival skills" education in the hospital and referral to community sources for ongoing patient education following discharge.

At discharge, the patient’s preadmission regimen – either insulin or oral and noninsulin injectable antidiabetic drugs – can be reinstituted so long as the patient’s preadmission glycemic control was good and there are no contraindications. To assess safety and efficacy, insulin administration should be initiated at least 1 day before discharge. Patients and their caregivers should receive oral and written instructions for home glycemic management.

The guidelines also address transition from intravenous to subcutaneous insulin therapy, glycemic management of patients who are receiving enteral or parenteral nutrition, perioperative blood glucose control, and management of glucocorticoid-induced diabetes.

<[stk -3]>The panel recommended the development of protocols with specific directions for avoiding and managing hypoglycemia as well as the implementation of hospital-wide, nurse-initiated hypoglycemia treatment protocols and a system for tracking with root cause analysis the frequency of hypoglycemic events. The document lists key components of such protocols, and provides suggested nurse-initiated strategies.<[etk]>

<[stk -3]>Hospitals are advised to provide administrative support for an interdisciplinary steering committee targeting a systems approach to improve care of inpatients with hyperglycemia and diabetes. Uniform methods for collecting and evaluating point-of-care testing data and insulin use information in hospitals are recommended, as are the provision of accurate devices for glucose measurement at the bedside with ongoing staff education and competency assessments.

Dr. Hellman and Dr. Umpierrez have no financial disclosures, but three other members of the guideline panel declared relationships with manufacturers of diabetes-related products.

All patients admitted to the hospital in noncritical care settings should have their blood glucose tested, according to a new clinical practice guideline from the Endocrine Society.

Unlike previous guidelines based largely on data from intensive care and critical care settings, the new guideline focuses on glucose management in noncritical settings, with special emphasis on systemic issues such as patient transition between hospital units and from inpatient to outpatient settings. The guidelines also include detailed guidance for creating systems and protocols to ensure optimal patient management and safety (Diabetes Care [2009;32:1119-31]).

"Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Setting: An Endocrine Society Clinical Practice Guideline" was developed by an eight-member panel with representatives from the American Diabetes Association, American Heart Association, American Association of Diabetes Educators, European Society of Endocrinology, and the Society of Hospital Medicine. The lead author was Dr. Guillermo E. Umpierrez, professor of medicine at Emory University, and chief of diabetes and endocrinology at Grady Memorial Hospital, both in Atlanta.

The guideline has eight sections, all focused on the noncritical hospital setting: diagnosis and recognition of hyperglycemia and diabetes, monitoring glycemia, glycemic targets, management of hyperglycemia, special situations, recognition and management of hypoglycemia, implementation of a glycemic control program, and patient and professional education.

The panel’s advice was characterized as "recommended" for items with strong evidence and "suggested" for items with less evidence. In the first of the guideline’s eight sections, the panel recommended all patients be assessed on admission for a history of diabetes and suggested laboratory blood glucose testing on admission for all patients, regardless of prior diagnosis of diabetes.

"There’s abundant data to show that a very large number of people … [are admitted] with undiagnosed diabetes and people also develop stress hyperglycemia" and both conditions affect patient outcomes, Dr. Richard Hellman said in an interview. Dr. Hellman is a coauthor of the guidelines and an endocrinologist who is a clinical professor of medicine at the University of Missouri–Kansas City.

<[stk -3]>While the accuracy of point-of-care testing is not optimal, the panel recommended bedside glucose testing of capillary blood because of the need to time glucose measures to the patient’s nutritional intake and medication regimens. Personal glucose meters should not be used, and continuous glucose monitors while "promising," have not been adequately tested in acute care and therefore can’t be recommended for hospital use at this time, Dr. Umpierrez and his associates wrote.<[etk]>

As in the 2009 guideline that addressed critical care patients, the glycemic targets are less than 140 mg/dL premeal and less than 180 mg/dL random for the majority of hospitalized patients with noncritical illness. Lower targets might be considered among patients who are able to achieve them without hypoglycemia, while higher targets might be appropriate for those at high risk for hypoglycemia and those with a limited life expectancy.

Medical nutrition therapy is recommended as a component of the glycemic management program for all hospitalized patients with diabetes and hyperglycemia. Meals with consistent amounts of carbohydrate are suggested to help coordinate dosing of rapid-acting insulin.

Insulin therapy is the preferred method for achieving glycemic control in all hospitalized patients with diabetes and hyperglycemia, the panel said. At admission, they suggested, oral hypoglycemic agents should be discontinued and insulin therapy should be initiated in acutely ill patients with type 2 diabetes. Oral agents are contraindicated in hospitalized patients with decompensated heart failure, renal insufficiency, hypoperfusion, or chronic pulmonary disease, and in any patient given intravenous contrast dye, the authors noted.

<[stk -3]>For patients who are eating, the panel recommended scheduled subcutaneous basal or intermediate-acting insulin once or twice daily in combination with rapid- or short-acting insulin administered before meals. <[etk]>

Prolonged use of sliding-scale therapy should be avoided as the sole method for glycemic control, the panel wrote.

"There’s abundant data to show that a very large number of people [are admitted] with undiagnosed diabetes and people also develop stress hyperglycemia."

<[stk -3]>Two recent studies led by Dr. Umpierrez show basal-bolus insulin regimens to be superior to sliding scale insulin treatment. One of those studies was done in noncritically ill hospitalized patients with type 2 diabetes (Diabetes Care 2007;30:2181-6), and the other was done in type 2 patients undergoing general surgery (Diabetes Care 2011;34:256-61). <[etk]>

Diabetes self-management education is recommended for patients, including both short-term "survival skills" education in the hospital and referral to community sources for ongoing patient education following discharge.

At discharge, the patient’s preadmission regimen – either insulin or oral and noninsulin injectable antidiabetic drugs – can be reinstituted so long as the patient’s preadmission glycemic control was good and there are no contraindications. To assess safety and efficacy, insulin administration should be initiated at least 1 day before discharge. Patients and their caregivers should receive oral and written instructions for home glycemic management.

The guidelines also address transition from intravenous to subcutaneous insulin therapy, glycemic management of patients who are receiving enteral or parenteral nutrition, perioperative blood glucose control, and management of glucocorticoid-induced diabetes.

<[stk -3]>The panel recommended the development of protocols with specific directions for avoiding and managing hypoglycemia as well as the implementation of hospital-wide, nurse-initiated hypoglycemia treatment protocols and a system for tracking with root cause analysis the frequency of hypoglycemic events. The document lists key components of such protocols, and provides suggested nurse-initiated strategies.<[etk]>

<[stk -3]>Hospitals are advised to provide administrative support for an interdisciplinary steering committee targeting a systems approach to improve care of inpatients with hyperglycemia and diabetes. Uniform methods for collecting and evaluating point-of-care testing data and insulin use information in hospitals are recommended, as are the provision of accurate devices for glucose measurement at the bedside with ongoing staff education and competency assessments.

Dr. Hellman and Dr. Umpierrez have no financial disclosures, but three other members of the guideline panel declared relationships with manufacturers of diabetes-related products.

All patients admitted to the hospital in noncritical care settings should have their blood glucose tested, according to a new clinical practice guideline from the Endocrine Society.

Unlike previous guidelines based largely on data from intensive care and critical care settings, the new guideline focuses on glucose management in noncritical settings, with special emphasis on systemic issues such as patient transition between hospital units and from inpatient to outpatient settings. The guidelines also include detailed guidance for creating systems and protocols to ensure optimal patient management and safety (Diabetes Care [2009;32:1119-31]).

"Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Setting: An Endocrine Society Clinical Practice Guideline" was developed by an eight-member panel with representatives from the American Diabetes Association, American Heart Association, American Association of Diabetes Educators, European Society of Endocrinology, and the Society of Hospital Medicine. The lead author was Dr. Guillermo E. Umpierrez, professor of medicine at Emory University, and chief of diabetes and endocrinology at Grady Memorial Hospital, both in Atlanta.

The guideline has eight sections, all focused on the noncritical hospital setting: diagnosis and recognition of hyperglycemia and diabetes, monitoring glycemia, glycemic targets, management of hyperglycemia, special situations, recognition and management of hypoglycemia, implementation of a glycemic control program, and patient and professional education.

The panel’s advice was characterized as "recommended" for items with strong evidence and "suggested" for items with less evidence. In the first of the guideline’s eight sections, the panel recommended all patients be assessed on admission for a history of diabetes and suggested laboratory blood glucose testing on admission for all patients, regardless of prior diagnosis of diabetes.

"There’s abundant data to show that a very large number of people … [are admitted] with undiagnosed diabetes and people also develop stress hyperglycemia" and both conditions affect patient outcomes, Dr. Richard Hellman said in an interview. Dr. Hellman is a coauthor of the guidelines and an endocrinologist who is a clinical professor of medicine at the University of Missouri–Kansas City.

<[stk -3]>While the accuracy of point-of-care testing is not optimal, the panel recommended bedside glucose testing of capillary blood because of the need to time glucose measures to the patient’s nutritional intake and medication regimens. Personal glucose meters should not be used, and continuous glucose monitors while "promising," have not been adequately tested in acute care and therefore can’t be recommended for hospital use at this time, Dr. Umpierrez and his associates wrote.<[etk]>

As in the 2009 guideline that addressed critical care patients, the glycemic targets are less than 140 mg/dL premeal and less than 180 mg/dL random for the majority of hospitalized patients with noncritical illness. Lower targets might be considered among patients who are able to achieve them without hypoglycemia, while higher targets might be appropriate for those at high risk for hypoglycemia and those with a limited life expectancy.

Medical nutrition therapy is recommended as a component of the glycemic management program for all hospitalized patients with diabetes and hyperglycemia. Meals with consistent amounts of carbohydrate are suggested to help coordinate dosing of rapid-acting insulin.

Insulin therapy is the preferred method for achieving glycemic control in all hospitalized patients with diabetes and hyperglycemia, the panel said. At admission, they suggested, oral hypoglycemic agents should be discontinued and insulin therapy should be initiated in acutely ill patients with type 2 diabetes. Oral agents are contraindicated in hospitalized patients with decompensated heart failure, renal insufficiency, hypoperfusion, or chronic pulmonary disease, and in any patient given intravenous contrast dye, the authors noted.

<[stk -3]>For patients who are eating, the panel recommended scheduled subcutaneous basal or intermediate-acting insulin once or twice daily in combination with rapid- or short-acting insulin administered before meals. <[etk]>

Prolonged use of sliding-scale therapy should be avoided as the sole method for glycemic control, the panel wrote.

"There’s abundant data to show that a very large number of people [are admitted] with undiagnosed diabetes and people also develop stress hyperglycemia."

<[stk -3]>Two recent studies led by Dr. Umpierrez show basal-bolus insulin regimens to be superior to sliding scale insulin treatment. One of those studies was done in noncritically ill hospitalized patients with type 2 diabetes (Diabetes Care 2007;30:2181-6), and the other was done in type 2 patients undergoing general surgery (Diabetes Care 2011;34:256-61). <[etk]>

Diabetes self-management education is recommended for patients, including both short-term "survival skills" education in the hospital and referral to community sources for ongoing patient education following discharge.

At discharge, the patient’s preadmission regimen – either insulin or oral and noninsulin injectable antidiabetic drugs – can be reinstituted so long as the patient’s preadmission glycemic control was good and there are no contraindications. To assess safety and efficacy, insulin administration should be initiated at least 1 day before discharge. Patients and their caregivers should receive oral and written instructions for home glycemic management.

The guidelines also address transition from intravenous to subcutaneous insulin therapy, glycemic management of patients who are receiving enteral or parenteral nutrition, perioperative blood glucose control, and management of glucocorticoid-induced diabetes.

<[stk -3]>The panel recommended the development of protocols with specific directions for avoiding and managing hypoglycemia as well as the implementation of hospital-wide, nurse-initiated hypoglycemia treatment protocols and a system for tracking with root cause analysis the frequency of hypoglycemic events. The document lists key components of such protocols, and provides suggested nurse-initiated strategies.<[etk]>

<[stk -3]>Hospitals are advised to provide administrative support for an interdisciplinary steering committee targeting a systems approach to improve care of inpatients with hyperglycemia and diabetes. Uniform methods for collecting and evaluating point-of-care testing data and insulin use information in hospitals are recommended, as are the provision of accurate devices for glucose measurement at the bedside with ongoing staff education and competency assessments.

Dr. Hellman and Dr. Umpierrez have no financial disclosures, but three other members of the guideline panel declared relationships with manufacturers of diabetes-related products.