Identifying Risk Factors for Severe Hypoglycemia in Hospitalized Patients with Diabetes

179

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC. In the hospital, both hyperglycemia and hypoglycemia are associated with adverse outcomes, including death (1,2). Therefore, inpatient goals should include the prevention of both hyperglycemia and hypoglycemia. Hospitals should promote the shortest safe hospital stay and provide an effective transition out of the hospital that prevents acute complications and readmission. For in-depth review of inpatient hospital practice, consult recent reviews that focus on hospital care for diabetes (3,4). HOSPITAL CARE DELIVERY STANDARDS Recommendation 15.1 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. B High-quality hospital care for diabetes requires both hospital care delivery standards, often assured by structured order sets, and quality assurance standards for process improvement. "Best practice" protocols, reviews, and guidelines (2) are inconsistently implemented within hospitals. To correct this, hospitals have established protocols for structured patient care and structured order sets, which include computerized physician order entry (CPOE). Considerations on Admission Initial orders should state the type of diabetes (i.e., type 1 or type 2 diabetes) or no previous history of diabetes. Because inpatient insulin use (5) and discharge orders (6) can be more effective if based on an A1C level on admission (7), perform an A1C test on all patients with diabetes or hyperglycemia admitted to the hospital if the test has not been performed in the prior 3 months (8). In addition, diabetes self-management knowledge and behaviors should be assessed on admission and

Section: Predictors Of Hypoglycemiamentioning

confidence: 99%

15. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2019

2018

179

“…In one study, 84% of patients with an episode of severe hypoglycemia (,40 mg/dL [2.2 mmol/L]) had a prior episode of hypoglycemia (,70 mg/dL [3.9 mmol/L]) during the same admission (47). In another study of hypoglycemic episodes (,50 mg/dL [2.8 mmol/L]), 78% of patients were using basal insulin, with the incidence of hypoglycemia peaking between midnight and 6 A.M.…”

Section: Predictors Of Hypoglycemiamentioning

confidence: 99%

14. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2018

2017

154

The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes” includes ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA’s clinical practice recommendations, please refer to the Standards of Care Introduction. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

“…In one study, 84% of patients with an episode of severe hypoglycemia (,40 mg/dL [2.2 mmol/L]) had a prior episode of hypoglycemia (,70 mg/dL [3.9 mmol/L]) during the same admission (36). In another study of hypoglycemic episodes (,50 mg/dL [2.8 mmol/L]), 78% of patients were using basal insulin, with the incidence of hypoglycemia peaking between midnight and 6 A.M.…”

Section: Predictors Of Hypoglycemiamentioning

confidence: 99%

14. Diabetes Care in the Hospital

2016

Recommendations c Perform an A1C for all patients with diabetes or hyperglycemia admitted to the hospital if not performed in the prior 3 months. B c 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 A and noncritically ill patients. C c More stringent goals, such as ,140 mg/dL (,7.8 mmol/L), may be appropriate for selected patients, as long as this can be achieved without significant hypoglycemia. C c Intravenous insulin infusions should be administered using validated written or computerized protocols that allow for predefined adjustments in the insulin infusion rate based on glycemic fluctuations and insulin dose. E c Basal insulin or a basal plus bolus correction insulin regimen is the preferred treatment for noncritically ill patients with poor oral intake or those who are taking nothing by mouth. An insulin regimen with basal, nutritional, and correction components is the preferred treatment for noncritically ill hospitalized patients with good nutritional intake. A c Sole use of sliding scale insulin in the inpatient hospital setting is strongly discouraged. A c 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. E c The treatment regimen should be reviewed and changed as necessary to prevent further hypoglycemia when a blood glucose value is ,70 mg/dL (3.9 mmol/L). C c There should be a structured discharge plan tailored to the individual patient with diabetes. B HOSPITAL CARE DELIVERY STANDARDS High-quality hospital care for diabetes requires both hospital care delivery standards, often assured by structured order sets, and quality assurance standards for process improvement. "Best practice" protocols, reviews, and guidelines (2) are inconsistently implemented within hospitals. To correct this, hospitals have established protocols for structured patient care and structured order sets, which include computerized physician order entry (CPOE). Considerations on Admission Initial orders should state the type of diabetes (i.e., type 1 or type 2 diabetes) or no previous history of diabetes. Because inpatient insulin use (5) and discharge orders (6) can be more effective if based on an A1C level on admission (7), perform an A1C test on all patients with diabetes or hyperglycemia admitted to the hospital if the Suggested citation: American Diabetes Association. Diabetes care in the hospital. Sec. 14. In Standards of Medical Care in Diabetesd2017.