differences and similarities between the three forms of nursing inquiry: quality improvement (QI), research, and evidence-based practice (EBP).

15. Diabetes Care in the Hospital: Standards of Medical Care in Diabetesd2019 Diabetes Care 2019;42(Suppl. 1):S173–S181 | https://doi.org/10.2337/dc19-S015

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 theADAProfessional 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 stan- dards, 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 estab- lished 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

Suggested citation: American Diabetes Associa- tion. 15. Diabetes care in the hospital: Standards of Medical Care in Diabetesd2019. Diabetes Care 2019;42(Suppl. 1):S173–S181

© 2018 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. More infor- mation is available at http://www.diabetesjournals .org/content/license.

American Diabetes Association

Diabetes Care Volume 42, Supplement 1, January 2019 S173

15. D IA B ETES

C A R E IN

TH E H O SP ITA

L

diabetes self-management education should be provided, if appropriate. Diabetes self-management education should include appropriate skills needed after discharge, such as taking antihyper- glycemic medications, monitoring glu- cose, and recognizing and treating hypoglycemia (2).

Physician Order Entry

Recommendation

15.2 Insulin should be administered using validated written or com- puterized protocols that allow for predefined adjustments in the insulin dosage based on glycemic fluctuations. E

The National Academy of Medicine rec- ommends CPOE to prevent medication- related errors and to increase efficiency in medication administration (9). A Co- chrane review of randomized controlled trials using computerized advice to im- prove glucose control in the hospital found significant improvement in the percentage of time patients spent in the target glucose range, lower mean blood glucose levels, and no increase in hypoglycemia (10). 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 (11).

Diabetes Care Providers in theHospital

Recommendation

15.3 When caring for hospitalized patientswith diabetes, consider consulting with a specialized di- abetes or glucose management team where possible. E

Appropriately trained specialists or spe- cialty teams may reduce length of stay, improve glycemic control, and improve outcomes, but studies are few (12,13). A call to action outlined the studies needed to evaluate these outcomes (14). People with diabetes are known to have a higher risk of 30-day readmission following hos- pitalization. Specialized diabetes teams caring for patients with diabetes during their hospital stay can improve readmis- sion rates and lower cost of care (15,16).

Early evidence suggests that virtual glu- cose management services may be used to improve glycemic outcomes in hospital- ized patients and facilitate transition of care after discharge (17). Details of team formation are available from the Joint Commission standards for programs and the Society of Hospital Medicine (18,19).

Quality Assurance Standards 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 dia- betes (18), and the Society of Hospital Medicine has a workbook for program development (19).

GLYCEMIC TARGETS IN HOSPITALIZED PATIENTS

Recommendations

15.4 Insulin therapy shouldbe initiated for treatment of persistent hyper- glycemia 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 non- critically ill patients. A

15.5 More stringent goals, such as 110–140mg/dL (6.1–7.8 mmol/L), may be appropriate for se- lected patients, if this can be achieved without significant hypoglycemia. C

Standard Definition of Glucose Abnormalities Hyperglycemia in hospitalized patients is defined as blood glucose levels .140 mg/dL (7.8 mmol/L) (2,20). Blood glu- cose levels that are persistently above this level may require alterations in diet or a change in medications that cause hyperglycemia. An admission A1C value $6.5% (48 mmol/mol) suggests that diabetes preceded hospitalization (see Section 2 “Classification and Diagnosis of Diabetes”) (2,20). Level 1 hypoglyce- mia in hospitalized patients is defined as a measurable glucose concentration ,70 mg/dL (3.9 mmol/L) but $54 mg/dL (3.0 mmol/L). Level 2 hypoglycemia (defined as a blood glucose concentration ,54 mg/dL [3.0 mmol/L]) is the threshold

at which neuroglycopenic symptoms begin to occur and requires immediate action to resolve the hypoglycemic event. Lastly, level 3 hypoglycemia is defined as a severe event characterized by altered mental and/or physical functioning that requires assistance from another person for recovery. See Table 15.1 for levels of hypoglycemia (21). Hypoglycemia is dis- cussed more fully below.

Moderate Versus Tight Glycemic Control A meta-analysis of over 26 studies, includ- ing the Normoglycemia in Intensive Care Evaluation–Survival Using Glucose Algo- rithm Regulation (NICE-SUGAR) study, showed increased rates of “severe hy- poglycemia” (defined in the analysis as blood glucose,40 mg/dL [2.2 mmol/L]) andmortality in cohortswith tight versus moderate glycemic control (22). Recent randomized controlled studies and meta- analyses in surgical patients have also reported that targeting perioperative blood glucose levels to,180 mg/dL (10- mmol/L) is associatedwith lower rates of mortality and stroke compared with a tar- get glucose ,200 mg/dL (11.1 mmol/L), whereas no significant additional benefit was found with more strict glycemic control (,140 mg/dL [7.8 mmol/L]) (23,24). Insulin therapy should be initiated for treatment of persistent hyperglyce- mia 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 recom- mended for the majority of critically ill and noncritically ill patients (2). 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 hypoglyce- mia. Conversely, higher glucose ranges may be acceptable in terminally ill patients,

Table 15.1—Levels of hypoglycemia (21)

Level Glycemic

criteria/description

Level 1 Glucose ,70 mg/dL (3.9 mmol/L) and glucose $54 mg/dL (3.0 mmol/L)

Level 2 Glucose ,54 mg/dL (3.0 mmol/L)

Level 3 A severe event characterized by altered mental and/or physical status requiring assistance

S174 Diabetes Care in the Hospital Diabetes Care Volume 42, Supplement 1, January 2019

in patients with severe comorbidities, and in inpatient care settings where frequent glucose monitoring or close nursing su- pervision is not feasible. Clinical judgment combined with on-

going assessment of the patient’s clinical status, including changes in the trajec- tory of glucosemeasures, illness severity, nutritional status, or concomitant med- ications that might affect glucose levels (e.g., glucocorticoids), should be incor- porated into the day-to-day decisions regarding insulin dosing (2).

BEDSIDE BLOOD GLUCOSE MONITORING

Indications In the patient who is eating meals, glu- cose monitoring should be performed before meals. In the patient who is not eating, glucose monitoring is advised every 4–6 h (2). More frequent blood glucose testing ranging from every 30 min to every 2 h is required for patients receiving intravenous insulin. Observational studies have shown that safety standards should be established for blood glucose monitoring that pro- hibit the sharing of fingerstick lancing devices, lancets, and needles (25).

Point-of-Care Meters Point-of-care (POC) meters have limi- tations for measuring blood glucose. Although the U.S. Food and Drug Ad- ministration (FDA) has standards for blood glucose meters used by lay per- sons, there have been questions about the appropriateness of these criteria, especially in the hospital and for lower blood glucose readings (26). Significant discrepancies between capillary, venous, and arterial plasma samples have been observed in patients with low or high hemoglobin concentrations and with hy- poperfusion. Any glucose result that does not correlate with the patient’s clinical status should be confirmed through con- ventional laboratory glucose tests. The FDA established a separate category for POCglucosemeters for use in health care settings and has released guidance on in-hospital use with stricter standards (27). Before choosing a device for in- hospital use, consider the device’s ap- proval status and accuracy.

Continuous Glucose Monitoring Real-time continuous glucose monitor- ing (CGM) provides frequent measure- ments of interstitial glucose levels, as

well as direction andmagnitude of glucose trends, which may have an advantage over POC glucose testing in detecting and reducing the incidence of hypoglycemia in the hospital setting (28,29). Several in- patient studies have shown that CGM use did not improve glucose control but detected a greater number of hypogly- cemic events than POC testing (30,31). However, a recent review has recom- mended against using CGM in adults in a hospital setting until more safety and efficacy data become available (30). For more information on CGM, see Section 7 “Diabetes Technology.”

ANTIHYPERGLYCEMIC AGENTS IN HOSPITALIZED PATIENTS

Recommendations

15.6 Basal insulin or a basal plus bolus correction insulin regimen is the preferred treatment for noncriti- cally ill hospitalized patients with poor oral intake or those who are taking nothing by mouth. An in- sulin regimen with basal, pran- dial, and correction components is the preferred treatment for noncritically ill hospitalized pa- tients with good nutritional in- take. A

15.7 Sole use of sliding scale insulin in the inpatient hospital setting is strongly discouraged. A

In most instances in the hospital setting, insulin is the preferred treatment for hyperglycemia (2). However, in certain circumstances, it may be appropriate to continue home regimens including oral antihyperglycemic medications (32). If oral medications are held in the hospital, there should be a protocol for resuming them 1–2 days before discharge. Insulin pens are the subject of an FDA warning because of potential blood-borne dis- eases, and care should be taken to follow the label insert “For single patient use only” (33). Recent reports, however, have indicated that the inpatient use of insulin pens appears to be safe and may be associated with improved nurse satisfaction compared with the use of insulin vials and syringes (34–36).

Insulin Therapy

Critical Care Setting

In the critical care setting, continuous intravenous insulin infusion has been

shown tobe thebestmethod for achieving glycemic targets. Intravenous insulin infu- sions should be administered based on validated written or computerized proto- cols that allow for predefined adjustments in the infusion rate, accounting for glyce- mic fluctuations and insulin dose (2).

Noncritical Care Setting

Outside of critical care units, scheduled insulin regimens are recommended to manage hyperglycemia in patients with diabetes. Regimens using insulin analogs

and human insulin result in similar gly-

cemic control in the hospital setting (37). The use of subcutaneous rapid- or short-

acting insulin beforemeals or every 4–6 h

if no meals are given or if the patient is

receiving continuous enteral/parenteral

nutrition is indicated to correct hyper-

glycemia (2). Basal insulin or a basal plus

bolus correction insulin regimen is the

preferred treatment for noncritically ill

hospitalized patients with poor oral in-

take or those who are taking nothing by

mouth (NPO). An insulin regimen with

basal, prandial, and correction compo-

nents is the preferred treatment for

noncritically ill hospitalized patients with

good nutritional intake. If the patient is eating, insulin injec-

tions should align with meals. In such

instances, POC glucose testing should

be performed immediately before meals.

If oral intake is poor, a safer procedure is

to administer the rapid-acting insulin

immediately after the patient eats or

to count the carbohydrates and cover

the amount ingested (37). A randomized controlled trial has

shown that basal-bolus treatment im-

proved glycemic control and reduced

hospital complications compared with

sliding scale insulin in general surgery

patients with type 2 diabetes (38). Pro-

longed sole use of sliding scale insulin in

the inpatient hospital setting is strongly

discouraged (2,14). While there is evidence for using pre-

mixed insulin formulations in the out-

patient setting (39), a recent inpatient

study of 70/30 NPH/regular insulin ver-

sus basal-bolus therapy showed compa-

rable glycemic control but significantly

increased hypoglycemia in the group re-

ceiving premixed insulin (40). Therefore,

premixed insulin regimens are not rou-

tinely recommended for in-hospital use.

care.diabetesjournals.org Diabetes Care in the Hospital S175

Type 1 Diabetes

For patients with type 1 diabetes, dosing insulin based solely on premeal glucose levels does not account for basal insulin requirements or caloric intake, increas- ing both hypoglycemia and hyperglyce- mia risks. Typically, basal insulin dosing schemes are based on body weight, with some evidence that patients with renal insufficiency should be treated with lower doses (41). An insulin regimen with basal and correction components is necessary for all hospitalized patients with type 1 diabetes, with the addition of prandial insulin if the patient is eating.

Transitioning Intravenous to

Subcutaneous Insulin

When discontinuing intravenous insu- lin, a transition protocol is associated with less morbidity and lower costs of care (42) and is therefore recommended. A patient with type 1 or type 2 diabetes being transitioned to outpatient subcu- taneous insulin should receive subcuta- neous basal insulin 2–4 h before the intravenous insulin is discontinued. Con- verting to basal insulin at 60–80% of the daily infusion dose has been shown to be effective (2,42,43). For patients continu- ing regimens with concentrated insulin (U-200, U-300, or U-500) in the inpatient setting, it is important to ensure the correct dosing by utilizing an individual pen and cartridge for each patient, me- ticulous pharmacist supervision of the dose administered, or other means (44,45).

Noninsulin Therapies The safety and efficacy of noninsulin antihyperglycemic therapies in the hos- pital setting is an area of active research. A few recent randomized pilot trials in general medicine and surgery patients reported that a dipeptidyl peptidase 4 inhibitor alone or in combination with basal insulin was well tolerated and resulted in similar glucose control and frequency of hypoglycemia compared with a basal-bolus regimen (46–48). However, an FDA bulletin states that providers should consider discontinu- ing saxagliptin and alogliptin in people who develop heart failure (49). A review of antihyperglycemic medications con- cluded that glucagon-like peptide 1 re- ceptor agonists show promise in the inpatient setting (50); however, proof of safety and efficacy awaits the results of randomized controlled trials (51).

Moreover, the gastrointestinal symp- toms associated with the glucagon-like peptide 1 receptor agonists may be problematic in the inpatient setting.

Regarding the sodium–glucose trans- porter 2 (SGLT2) inhibitors, the FDA includes warnings about diabetic keto- acidosis (DKA) and urosepsis (52), urinary tract infections, and kidney injury (53) on the drug labels. A recent review suggested SGLT2 inhibitors be avoided in severe illness, when ketone bodies are present, and during prolonged fasting and surgical procedures (3). Until safety and effec- tiveness are established, SGLT2 inhibitors cannot be recommended for routine in-hospital use.

HYPOGLYCEMIA

Recommendations

15.8 A hypoglycemia management protocol should be adopted and implemented by each hospital or hospital system. A plan for pre- venting and treating hypoglyce- mia should be established for each patient. Episodes of hypo- glycemia in the hospital should be documented in the medical record and tracked. E

15.9 The treatment regimen should be reviewed and changed as nec- essary to prevent further hypogly- cemiawhen a blood glucose value of ,70 mg/dL (3.9 mmol/L) is documented. C

Patients with or without diabetes may ex- perience hypoglycemia in the hospital set- ting. While hypoglycemia is associated with increased mortality (54), hypoglycemia may be a marker of underlying disease rather than the cause of increased mor- tality. However, until it is provennot to be causal, it is prudent to avoid hypoglycemia. Despite the preventable nature of many inpatient episodes of hypoglycemia, insti- tutions are more likely to have nursing pro- tocols for hypoglycemia treatment than for its prevention when both are needed.

A hypoglycemia prevention and man- agement protocol should be adopted and implemented by each hospital or hospital system. There should be a stan- dardized hospital-wide, nurse-initiated hypoglycemia treatment protocol to immediately address blood glucose lev- els of ,70 mg/dL (3.9 mmol/L), as well as individualized plans for preventing

and treating hypoglycemia for each pa- tient. An American Diabetes Association (ADA) consensus report suggested that a patient’s overall treatment regimen be reviewed when a blood glucose value of ,70 mg/dL (3.9 mmol/L) is identified because such readings often predict im- minent level 3 hypoglycemia (2).

Episodes of hypoglycemia in the hos- pital should be documented in the med- ical record and tracked (2).

Triggering Events Iatrogenic hypoglycemia triggers may in- clude sudden reduction of corticosteroid dose, reduced oral intake, emesis, new NPO status, inappropriate timing of short- or rapid-acting insulin in relation to meals, reduced infusion rate of intravenous dextrose, unexpected interruption of oral, enteral, or parenteral feedings, and al- tered ability of the patient to report symptoms (3).

Predictors of Hypoglycemia In one study, 84% of patients with an episode of “severe hypoglycemia” (de- fined as,40 mg/dL [2.2 mmol/L]) had a prior episode of hypoglycemia (,70 mg/dL [3.9 mmol/L]) during the same ad- mission (55). In another study of hypo- glycemic episodes (defined as,50 mg/dL [2.8 mmol/L]), 78% of patients were using basal insulin, with the incidence of hypoglycemia peaking between mid- night and 6 A.M. Despite recognition of hypoglycemia, 75% of patients did not have their dose of basal insulin changed before the next insulin administration (56).

Prevention Common preventable sources of iatro- genic hypoglycemia are improper pre- scribing of hypoglycemic medications, inappropriate management of the first episode of hypoglycemia, and nutrition– insulin mismatch, often related to an unexpected interruption of nutrition. Studies of “bundled” preventative ther- apies including proactive surveillance of glycemic outliers and an interdisciplinary data-driven approach to glycemic man- agement showed that hypoglycemic epi- sodes in the hospital could be prevented. Compared with baseline, two such stud- ies found that hypoglycemic events fell by 56% to 80% (57,58). The Joint Com- mission recommends that all hypogly- cemic episodes be evaluated for a root

S176 Diabetes Care in the Hospital Diabetes Care Volume 42, Supplement 1, January 2019

cause and the episodes be aggregated and reviewed to address systemic issues.

MEDICAL NUTRITION THERAPY IN THE HOSPITAL

The goals of medical nutrition therapy in the hospital are to provide adequate calories to meet metabolic demands, optimize glycemic control, address per- sonal food preferences, and facilitate creation of a discharge plan. The ADA does not endorse any single meal plan or specified percentages of macronutrients. Current nutrition recommendations ad- vise individualization based on treatment goals, physiological parameters, andmed- ication use. Consistent carbohydrate meal plans are preferred by many hospitals as they facilitate matching the prandial in- sulin dose to the amount of carbohydrate consumed (59). Regarding enteral nutri- tional therapy, diabetes-specific formu- las appear to be superior to standard formulas in controlling postprandial glu- cose, A1C, and the insulin response (60). When the nutritional issues in the

hospital are complex, a registered di- etitian, knowledgeable and skilled in medical nutrition therapy, can serve as an individual inpatient team member. That person should be responsible for integrating information about the pa- tient’s clinical condition, meal planning, and lifestyle habits and for establishing realistic treatment goals after discharge. Orders should also indicate that the meal delivery and nutritional insulin coverage should be coordinated, as their variability often creates the possibility of hypergly- cemic and hypoglycemic events.

SELF-MANAGEMENT IN THE HOSPITAL

Diabetes self-management in the hospi- tal may be appropriate for select youth and adult patients (61,62). Candidates include patients who successfully conduct self-management of diabetes at home, have the cognitive and physical skills needed to successfully self-administer insulin, and perform self-monitoring of blood glucose. In addition, they should have adequate oral intake, be proficient in carbohydrate estimation, use multi- ple daily insulin injections or continuous subcutaneous insulin infusion (CSII), have stable insulin requirements, and understand sick-day management. If self-management is to beused, a protocol should include a requirement that the

patient, nursing staff, and physician agree that patient self-management is appro- priate. If CSII is to be used, hospital policy and procedures delineating guidelines for CSII therapy, including the changing of infusion sites, are advised (63).

STANDARDS FOR SPECIAL SITUATIONS

Enteral/Parenteral Feedings For patients receiving enteral or paren- teral feedings who require insulin, insulin should be divided into basal, prandial, and correctional components. This is particularly important for people with type 1 diabetes to ensure that they continue to receive basal insulin even if the feedings are discontinued. One may use the patient’s preadmission basal in- sulin dose or a percentage of the total daily dose of insulin when the patient is being fed (usually 30–50% of the total daily dose of insulin) to estimate basal insulin requirements. However, if no basal insulin was used, consider using 5 units of NPH/detemir insulin subcuta- neously every 12 h or 10 units of insulin glargine every 24 h (64). For patients receiving continuous tube feedings, the total daily nutritional component may be calculated as 1 unit of insulin for every 10–15 g carbohydrate per day or as a percentage of the total daily dose of insulin when the patient is being fed (usually 50–70% of the total daily dose of insulin). Correctional insulin should also be administered subcutaneously every 6 h using human regular insulin or every 4 h using a rapid-acting insulin such as lispro, aspart, or glulisine. For patients receiving enteral bolus feedings, approximately 1 unit of regular human insulin or rapid-acting insulin per 10–15 g carbohydrate should be given subcuta- neously before each feeding.

Correctional insulin coverage should be added as needed before each feeding. For patients receiving continuous periph- eral or central parenteral nutrition, hu- man regular insulin may be added to the solution, particularly if .20 units of correctional insulin have been required in the past 24 h. A starting dose of 1 unit of human regular insulin for every 10 g dextrose has been recommended (65), to be adjusted daily in the solution. Correctional insulin should be admin- istered subcutaneously. For full enteral/ parenteral feeding guidance, the reader

is encouraged to consult review articles detailing this topic (2,66).

Glucocorticoid Therapy Glucocorticoid type and duration of ac- tion must be considered in determining insulin treatment regimens. Once-a-day, short-acting glucocorticoids such as prednisone peak in about 4–8 h (67), so coverage with intermediate-acting (NPH) insulin may be sufficient. For long-acting glucocorticoids such as dexa- methasone or multidose or continuous glucocorticoid use, long-acting insulin may be used (32,66). For higher doses of glucocorticoids, increasing doses of prandial and correctional insulin may be needed in addition to basal insulin (68). Whatever orders are started, adjust- ments based on anticipated changes in glucocorticoid dosing and POC glucose test results are critical.

Perioperative Care Many standards for perioperative care lack a robust evidence base. However, the following approach (69) may be considered:

1. Target glucose range for the perioper- ative period should be 80–180 mg/dL (4.4–10.0 mmol/L).

2. Perform a preoperative risk assess- ment for patients at high risk for ischemic heart disease and those with autonomic neuropathy or renal failure.

3. Withhold metformin the day of sur- gery.

4. Withhold any other oral hypoglycemic agents the morning of surgery or pro- cedure and give half of NPH dose or 60–80% doses of long-acting analog or pump basal insulin.

5.Monitor blood glucose at least every 4–6 h while NPO and dose with short- or rapid-acting insulin as needed.

A review found that perioperative glycemic control tighter than 80– 180 mg/dL (4.4–10.0 mmol/L) did not improve outcomes and was associated with more hypoglycemia (70); therefore, in general, tighter glycemic targets are not advised. A recent study reported that, compared with the usual insulin dose, on average an approximate 25% reduction in the insulin dose given the evening before surgery was more likely to achieve perioperative blood glucose

care.diabetesjournals.org Diabetes Care in the Hospital S177

levels in the target range with decreased risk for hypoglycemia (71). In noncardiac general surgery patients,

basal insulin plus premeal short- or rapid- acting insulin (basal-bolus) coverage has been associated with improved glycemic control and lower rates of perioperative complications compared with the tradi- tional sliding scale regimen (short- or rapid-acting insulin coverage only with no basal insulin dosing) (38,72).

Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State There is considerable variability in the pre- sentation of DKA and hyperosmolar hyper- glycemic state, ranging fromeuglycemia or mild hyperglycemia and acidosis to severe hyperglycemia, dehydration, and coma; therefore, treatment individualiza- tion based on a careful clinical and lab- oratory assessment is needed (73–76). Management goals include restora-

tion of circulatory volume and tissue perfusion, resolution of hyperglycemia, and correction of electrolyte imbalance and ketosis. It is also important to treat any correctable underlying cause of DKA such as sepsis. In critically ill and mentally obtunded

patients with DKA or hyperosmolar hy- perglycemic state, continuous intrave- nous insulin is the standard of care. Successful transition of patients from intravenous to subcutaneous insulin re- quires administration of basal insulin 2– 4 h prior to the intravenous insulin being stopped to prevent recurrence of keto- acidosis and rebound hyperglycemia (76). There is no significant difference in out- comes for intravenous human regular insulin versus subcutaneous rapid-acting analogs when combined with aggressive fluid management for treating mild or moderate DKA (77). Patients with un- complicated DKA may sometimes be treated with subcutaneous insulin in the emergency department or step- down units (78), an approach that may be safer and more cost-effective than treatment with intravenous insulin (79). If subcutaneous administration is used, it is important to provide adequate fluid replacement, nurse training, frequent bedside testing, infection treatment if warranted, and appropriate follow-up to avoid recurrent DKA. Several studies have shown that the use of bicarbonate in patients with DKA made no difference in resolution of acidosis or time to

discharge, and its use is generally not recommended (80). For further informa- tion regarding treatment, refer to recent in-depth reviews (3).

TRANSITION FROM THE ACUTE CARE SETTING

Recommendation

15.10 There should be a structured dischargeplan tailored to the in- dividual patient with diabetes. B

A structured discharge plan tailored to the individual patient may reduce length of hospital stay and readmission rates and increase patient satisfaction (81). Therefore, there should be a structured discharge plan tailored to each patient. Discharge planning should begin at ad- mission and be updated as patient needs change.

Transition from the acute care setting is a risky time for all patients. Inpatients may be discharged to varied settings, including home (with or without visiting nurse services), assisted living, rehabili- tation, or skilled nursing facilities. For the patient who is discharged to home or to assisted living, the optimal program will need to consider diabetes type and se- verity, effects of the patient’s illness on blood glucose levels, and the patient’s capacities and preferences. See Section 12 “Older Adults” for more information.

An outpatient follow-up visit with the primary care provider, endocrinologist, or diabetes educator within 1 month of discharge is advised for all patients hav- ing hyperglycemia in the hospital. If glycemic medications are changed or glucose control is not optimal at dis- charge, an earlier appointment (in 1–2 weeks) is preferred, and frequent con- tact may be needed to avoid hypergly- cemia and hypoglycemia. A recently described discharge algorithm for glyce- mic medication adjustment based on admission A1C found that use of the algorithm to guide treatment decisions resulted in significant improvements in the average A1C after discharge (6). Therefore, if an A1C from the prior 3 months is unavailable,measuring the A1C in all patients with diabetes or hyper- glycemia admitted to the hospital is recommended.

Clear communication with outpatient providers either directly or via hospital discharge summaries facilitates safe

transitions to outpatient care. Providing information regarding the cause of hy- perglycemia (or the plan for determining the cause), related complications and comorbidities, and recommended treat- ments can assist outpatient providers as they assume ongoing care.

The Agency for Healthcare Research and Quality (AHRQ) recommends that, at a minimum, discharge plans include the following (82):

Medication Reconciliation ○ The patient’s medications must be

cross-checked to ensure that no chronic medications were stopped and to ensure the safety of new prescriptions.

○ Prescriptions fornewor changedmed- ication should be filled and reviewed with the patient and family at or before discharge.

Structured Discharge Communication ○ Information on medication changes,

pending tests and studies, and follow- up needs must be accurately and promptly communicated to outpa- tient physicians.

○ Discharge summaries should be transmitted to the primary care pro- vider as soon as possible after dis- charge.

○ Appointment-keeping behavior is en- hanced when the inpatient team schedules outpatient medical follow- up prior to discharge.

It is recommended that the following areas of knowledge be reviewed and addressed prior to hospital discharge:

○ Identification of the health care pro- vider who will provide diabetes care after discharge.

○ Level of understanding related to the diabetes diagnosis, self-monitoring of blood glucose, home blood glucose goals, and when to call the provider.

○ Definition, recognition, treatment, and prevention of hyperglycemia and hy- poglycemia.

○ Information on making healthy food choices at home and referral to an outpatient registered dietitian nutri- tionist to guide individualization of meal plan, if needed.

○ If relevant, when and how to take blood glucose–lowering medications, including insulin administration.

S178 Diabetes Care in the Hospital Diabetes Care Volume 42, Supplement 1, January 2019

○ Sick-day management. ○ Properuseanddisposal ofneedles and

syringes.

It is important that patients be pro- vided with appropriate durable medical equipment, medications, supplies (e.g., blood glucose test strips), and prescrip- tions along with appropriate education at the time of discharge in order to avoid a potentially dangerous hiatus in care.

PREVENTING ADMISSIONS AND READMISSIONS

Preventing Hypoglycemic Admissions in Older Adults Insulin-treated patients 80 years of age or older are more than twice as likely to visit the emergency department and nearly five times as likely to be admitted for insulin-related hypoglycemia than those 45–64 years of age (83). However, older adults with type 2 diabetes in long-term care facilities taking either oral antihy- perglycemic agents or basal insulin have similar glycemic control (84), suggesting that oral therapy may be used in place of insulin to lower the risk of hypoglycemia for some patients. In addition, many older adults with diabetes are over- treated (85), with half of those maintain- ing an A1C ,7% (53 mmol/mol) being treated with insulin or a sulfonylurea, which are associated with hypoglycemia. To further lower the risk of hypoglyce- mia-related admissions in older adults, providers may, on an individual basis, relax A1C targets to 8% (64 mmol/mol) or 8.5% (69 mmol/mol) in patients with shortened life expectancies and signifi- cant comorbidities (refer to Section 12 “Older Adults” for detailed criteria).

Preventing Readmissions In patients with diabetes, the hospital re- admission rate is between14 and20% (86). Risk factors for readmission include lower socioeconomic status, certain ra- cial/ethnic minority groups, comorbid- ities, urgent admission, and recent prior hospitalization (86). Of interest, 30% of patients with two or more hospital stays account for over 50% of hospitalizations and their accompanying hospital costs (87). While there is no standard to pre- vent readmissions, several successful strategies have been reported, including an intervention program targeting ketosis- prone patients with type 1 diabetes (88), initiating insulin treatment in patients

with admission A1C.9% (75 mmol/mol) (89), and a transitional care model (90). For people with diabetic kidney dis- ease, patient-centered medical home collaboratives may decrease risk-adjusted readmission rates (91).

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