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Jan.10.2022

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 (American Diabetes Association) 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 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.
Assess current lifestyle patterns; acknowledging positive patterns supporting wellbeing.
Evaluate effectiveness of coping skills; encourage expression of feelings, expectations and concerns related to disease management and quality of life; reinforce education to enhance management plan and wellbeing.

Associated Documentation

Glycemic Management

Education

CPG-Specific Education Topics

Self-Management

participation with disease management p
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. American Diabetes Association Standards of Medical Care in Diabetes--2021. Diabetes Care. 2021, January;44(1), S1-S232. Source[Clinical Practice Guidelines]
American Diabetes Association. American Diabetes Association Standards of Medical Care in Diabetes--2021. Diabetes Care. 2021, January;44(1), S1-S232. Source[Clinical Practice Guidelines]
American Diabetes Association. Standards of Medical Care in Diabetes-2022. Diabetes Care. 2022;45(Supplement 1), S1-S264. doi:10.2337/dc22-Sint Source[Clinical Practice Guidelines]
American Diabetes Association. Standards of Medical Care in Diabetes-2022. Diabetes Care. 2022;45(Supplement 1), S1-S264. doi:10.2337/dc22-Sint Source[Clinical Practice Guidelines]
Azhar, A.; Gillani, S.W.; Mohiuddin, G.; Majeed, R. A. A systematic review on clinical implication of continuous glucose monitoring in diabetes management. Journal of Pharmacy and Bioallied Sciences. 2020;12(2), 102-111. doi:10.4103/jpbs.JPBS_7_20 [Systematic Review]
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]
Cosentino, F.; Grant, P. J.; Aboyans, V.; Bailey, C. J.; Ceriello, A.; Delgado, V.; et al. 2019 ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD. European Heart Journal. 2020;41, 255-323. doi:10.1093/eurheartj/ehz486 [Clinical Practice Guidelines]
Cruz, P. Inpatient hypoglycemia: the challenge remains. Journal of Diabetes Science and Technology. 2020;14(3), 560-566. doi:10.1177/193229682091854 [Review Articles]
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]
Davis, G. M.; Galindo, R. J.; Migdal, A. L.; Umpierrez, G. E. Diabetes Technology in the Inpatient Setting for Management of Hyperglycemia. Endocrinology Metabolic Clinics of North America. 2020;49(1), 79-93. doi:10.1016/j.ecl.2019.11.002 Source[Expert/Committee Opinion]
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]
Healthcare Improvement Scotland. (2010, Updated 2017). 116-Management of diabetes a national clinical guideline. Source[Quality Measures,Clinical Practice Guidelines]
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]
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]
National Institute for Health and Care Excellence. (2015 [Updated 2021, November]). Type 2 diabetes in adults: management. Source.[Clinical Practice Guidelines]
Pratiwi, C.; Mokoagow, M. I; Kshanti, I. A. M.; Soewondo, P. The risk factors of inpatient hypoglycemia: A systematic review. Heliyon. 2020;6 doi:10.1016/j.heliyon.2020.e03913 Source[Review Articles]
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]
Reyes-Garcia, R.; Mezquita-Raya, P.; Moreno-Perez, O.; Munoz-Torres, M.; Merino-Torres, J. F.; Pardo, R. M.; et al. Executive summary: Position document: Evaluation and management of hypoglycemia in the patient with diabetes mellitus 2020. Diabetes Mellitus Working Group of the Spanish Society of Endocrinology and Nutrition. Endocrinología, Diabetes y Nutrición. 2021;68(4), 270-276. doi:10.1016/j.endinu.2020.08.007 Source[Expert/Committee Opinion]
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.