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Jan.31.2020

Diabetes Comorbidity (Adult Inpatient)

Clinical Description

  • Care of the hospitalized patient with a known history of diabetes requiring glycemic monitoring and management.

Key Information

  • Carbohydrate-counting or carbohydrate-consistency has replaced the previous ADA calorie-restrictive diet (e.g., 1800 calorie ADA diet).
  • For patients who are on insulin pump therapy or insulin therapy, the total carbohydrate content of meals and snacks is a major determinant of premeal insulin dose.
  • Antihyperglycemic agents are not recommended for the hospitalized patient. Oral agents provide minimal flexibility and cannot be adjusted when there are sudden or unexpected events that may occur during hospitalization.
  • For hypoglycemia treatment, standards recommend providing a “fast-acting” carbohydrate and to retest within 15 minutes to ensure blood glucose level has stabilized per organizational protocol.

Clinical Goals

By transition of care

A. The patient will achieve the following goals:
  • Blood Glucose Level Within Targeted Range

B. Patient, family or significant other will teach back or demonstrate education topics and points:
  • Education: Self-Management

Correlate Health Status

  • Correlate health status to:

    • history, comorbidity
    • age, developmental level
    • sex, gender identity
    • baseline assessment data
    • physiologic status
    • response to medication and interventions
    • psychosocial status, social determinants of health
    • barriers to accessing care and services
    • health literacy
    • cultural and spiritual preferences
    • safety risks
    • family interaction
    • plan for transition of care

Diabetes Comorbidity

Signs/Symptoms/Presentation

  • Medical history of type 1 or type 2 diabetes

Problem Intervention

Monitor and Manage Glycemia

  • Establish target blood glucose levels based on patient-specific factors, such as age, diabetes-related complications and illness severity.
  • Document blood glucose levels and monitor trend; advocate for insulin regimen adjustment to keep within targeted range.
  • Provide pharmacologic therapy to maintain blood glucose levels within targeted range.
  • Check blood glucose level if there is a change in mental or cognitive status.
  • Recognize, treat and document hypoglycemia event and potential cause.
  • Avoid hypoglycemic episodes by advocating for insulin dose adjustment when there is a change in condition, such as illness severity, decreased oral intake, missed or refused meals and snacks, as well as medication change that may include steroid taper.

Associated Documentation

  • Glycemic Management

Education

CPG-Specific Education Topics

Self-Management

  • adherence to disease management plan

  • when to seek medical attention

General Education Topics

General Education

  • admission, transition of care

  • orientation to care setting, routine

  • advance care planning

  • diagnostic tests/procedures

  • diet modification

  • opioid medication management

  • oral health

  • medication management

  • pain assessment process

  • safe medication disposal

  • tobacco use, smoke exposure

  • treatment plan

Safety Education

  • call light use

  • equipment/home supplies

  • fall prevention

  • harm prevention

  • infection prevention

  • MDRO (multidrug-resistant organism) care

  • personal health information

  • resources for support

References

  • American Diabetes Association. Standards of medical care in diabetes. Diabetes Care. 2020;43(Supplement 1), S1-S211. doi:10.2337/dc20-SPPC Source[Quality Measures,Clinical Practice Guidelines]
  • Carlson, J. N.; Schunder-Tatzber, S.; Neilson, C. J.; Hood, N. Dietary sugars versus glucose tablets for first-aid treatment of symptomatic hypoglycaemia in awake patients with diabetes:  A systematic review and meta-analysis. Emergency Medicine Journal. 2017;34(2), 100-106. doi:10.1136/emermed-2015-205637 [Metasynthesis,Meta-analysis,Systematic Review]
  • Christensen, M. B.; Gotfredsen, A.; Nørgaard, K. Efficacy of basal-bolus insulin regimens in the inpatient management of non-critically ill patients with type 2 diabetes: A systematic review and meta-analysis. Diabetes/Metabolism Research and Reviews. 2017;33, e2885. doi:10.1002/dmrr.2885 Source[Metasynthesis,Meta-analysis,Systematic Review]
  • Cruz, P.; Blackburn, M. C.; Tobin, G. S. A systematic approach for the prevention and reduction of hypoglycemia in hospitalized patients. Current Diabetes Reports. 2017;17(11), 117. doi:10.1007/s11892-017-0934-8 Source[Metasynthesis,Meta-analysis,Systematic Review]
  • De Buck, E.; Borra, V.; Carlson, J. N.; Zideman, D. A.; Singletary, E. M.; Djärv, T. First aid glucose administration routes for symptomatic hypoglycaemia. Cochrane Database of Systematic Reviews. 2019;(4) doi:10.1002/14651858.CD013283.pub2 [Metasynthesis,Meta-analysis,Systematic Review]
  • Gordon, C. Blood glucose monitoring in diabetes: Rationale and procedure. British Journal of Nursing. 2019;28(7), 434-439. doi:10.12968/bjon.2019.28.7.434 Source[Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Handelsman, Y.; Bloomgarden, Z. T.; Grunberger, G.; Umpierrez, G.; Zimmerman, R. S.; Bailey, T. S.; Blonde, L.; Bray, G. A.; Cohen, A. J.; Dagogo-Jack, S.; Davidson, J. A.; Einhorn, D.; Ganda, O. P.; Garber, A. J.; Garvey, W. T.; Henry, R. R.; Hirsch, I. B.; Horton, E. S.; Hurley, D. L.; Jellinger, P. S.; Jovanovič, L.; Lebovitz, H. E.; LeRoith, D.; Levy, P.; McGill, J. B.; Mechanick, J. I.; Mestman, J. H.; Moghissi, E. S.; Orzeck, E. A.; Pessah-Pollack, R.; Rosenblit, P. D.; Vinik, A.; Wyne, K.; Zangeneh, F. American association of clinical endocrinologists and american college of endocrinology - clinical practice guidelines for developing a diabetes mellitus comprehensive care plan - 2015. Endocrine Practice. 2015;21(s1), 31778. doi:10.4158/EP15672.GL [Quality Measures,Clinical Practice Guidelines]
  • Healthcare Improvement Scotland. (2010, Updated 2017). 116-Management of diabetes a national clinical guideline. Source[Quality Measures,Clinical Practice Guidelines]
  • Kansagara, D.; Fu, R.; Freeman, M.; Wolf, F.; Helfand, M. Intensive insulin therapy in hospitalized patients:  A systematic review. Annals of Internal Medicine. 2011;154(4), 268-282. [Metasynthesis,Meta-analysis,Systematic Review]
  • Lake, A.; Arthur, A.; Byrne, C.; Davenport, K.; Yamamoto, J. M.; Murphy, H. R. The effect of hypoglycaemia during hospital admission on health-related outcomes for people with diabetes: A systematic review and meta-analysis. Diabetic Medicine. 2019;36, 1349-1359. doi:10.1111/dme.14115 Source[Metasynthesis,Meta-analysis,Systematic Review]
  • Malcolm, J.; Halperin, I.; Miller, D. B.; Moore, S.; Nerenberg, K A.; Woo, V.; Yu, C. H. In-hospital management of diabetes. Canadian Journal of Diabetes. 2018;42, S115-S123. doi:10.1016/j.jcjd.2017.10.014 [Quality Measures,Clinical Practice Guidelines]
  • Murad, M. H.; Coburn, J. A.; Coto-Yglesias, F.; Dzyubak, S.; Hazem, A.; Lane, M. A.; Prokop, L. J.; Montori, V. M. Glycemic control in non-critically ill hospitalized patients:  A systematic review and meta-analysis. Journal of Clinical Endocrinology & Metabolism. 2012;97(1), 49-58. doi:10.1210/jc.2011-2100 [Metasynthesis,Meta-analysis,Systematic Review]
  • National Institute for Health and Care Excellence (NICE). (2015 [updated 2016, Jul]). Type 1 diabetes in adults: Diagnosis and management of NICE guideline NG17. Source[Quality Measures,Clinical Practice Guidelines]
  • Pérez, A.; Ramos, A.; Carreras, G. Insulin therapy in hospitalized patients. American Journal of Therapeutics. 2020;27(1), e71-e78. doi:10.1097/MJT.0000000000001078 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Yale, J. F.; Paty, B.; Senior, P. A. 2018 Clinical Practice Guidelines: Hypoglycemia. Canadian Journal of Diabetes. 2018;42(1), S104-S108. doi:10.1016/j.jcjd.2017.10.010 Source[Quality Measures,Clinical Practice Guidelines]
  • Yatabe, T.; Inoue, S.; Sakaguchi, M.; Egi, M. The optimal target for accurate glycemic control in critically ill patients:  A network meta-analysis. Intensive Care Medicine. 2017;43(1), 16-28. [Metasynthesis,Meta-analysis,Systematic Review]

Disclaimer

Clinical Practice Guidelines represent a consistent/standardized approach to the care of patients with specific diagnoses. Care should always be individualized by adding patient specific information to the Plan of Care.