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Feb.11.2021

Diabetes Comorbidity (Pediatric Inpatient)

Clinical Description

  • Care of the hospitalized child 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: Comorbidity: Self-Management

Correlate Health Status

  • Correlate health status to:

    • history, comorbidity, congenital anomaly
    • 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
    • child and family/caregiver:
      • 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, developmental stage 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.
  • Encourage family participation in glycemic management.

Associated Documentation

  • Glycemic Management

Education

CPG-Specific Education Topics

Comorbidity: 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. 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]
  • Chiang, J. L.; Maahs, D. M.; Garvey, K. C.; Hood, K. K.; Laffel, L. M.; Weinzimer, S. A.; Wolfsdorf, J. I.; Schatz, D. Type 1 diabetes in children and adolescents: A position statement by the American Diabetes Association. Diabetes Care. 2018;41(9), 2026-2044. doi:10.2337/dci18-0023 Source[Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • 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]
  • DiMeglio, L. A.; Acerini, C. L.; Codner, E.; et al. ISPAD Clinical Practice Consensus Guidelines 2018: Glycemic control targets and glucose monitoring for children, adolescents, and young adults with diabetes. Pediatric Diabetes. 2018;19(Suppl. 27), 105-114. doi:10.1111/pedi.12737 Source[Quality Measures,Clinical Practice Guidelines]
  • 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]
  • Laffel, L. M.; Limbert, C.; PHelan, H.; Virmani, A.; Wood, J.; Hofer, S. E. ISPAD Clinical Practice Consensus Guidelines 2018: Sick day management in children and adolescents with diabetes. Pediatric Diabetes. 2018;19, 193-204. doi:10.1111/pedi.12741 [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]
  • Marks, B. E.; Wolfsdorf, J. I. Monitoring of pediatric type 1 diabetes. Frontiers in Endocrinology. 2020;11(128) doi:10.3389/fendo.2020.00128 Source[Review Articles]
  • National Institute for Health and Care Excellence. (2015). Diabetes (type 1 and type 2) in children and young people: Diagnosis and management. Source[Quality Measures,Clinical Practice Guidelines]
  • Panagiotopoulos, C.; Hadjiyannakis, S.; Henderson, M. Type 2 diabetes in children and adolescents. Canadian Journal of Diabetes. 2018;42, S247-S254. doi:10.1016/j.jcjd.2017.10.037 [Quality Measures,Clinical Practice Guidelines]
  • Phelan, H.; Lang, K.; Cengiz, E.; Gallego, P.; Majaliwa, E.; Pelicand, J.; Smart, C.; Hofer, S. E. ISPAD Clinical Practice Consensus Guidelines 2018: Diabetes education in children and adolescents. Pediatric Diabetes. 2018;19(Suppl 27), 75-83. doi:10.1111/pedi-12762 Source[Quality Measures,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]
  • Srinivasan, V.; Agus, M. S. D. Tight glucose control in critically ill children - A systematic review and meta-analysis. Pediatric Diabetes. 2014;15(2), 75-83. doi:10.1111/pedi.12134 [Metasynthesis,Meta-analysis,Systematic Review]
  • Wherrett, D. K.; Ho, J.; Huot, C.; Legault, L.; Nakhla, M.; Rosolowsky, E. Type 1 diabetes in children and adolescents. Canadian Journal of Diabetes. 2018;42, S234-S246. doi:10.1016/j.jcjd.2017.10.036 [Quality Measures,Clinical Practice Guidelines]
  • Wolfsdorf, J. I.; Glaser, N.; Agus, M.; Fritsch, M.; Hanas, R.; Rewers, A.; Sperling, M. A.; Codner, E. ISPAD Clinical Practice Consensus Guidelines 2018: Diabetic ketoacidosis and the hyperglycemic hyperosmolar state. Pediatric Diabetes. 2018;19(Suppl 27), 155-177. doi:10.1111/pedi.12701 [Quality Measures,Clinical Practice Guidelines]

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.

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