American Diabetes Association; 15. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2021. Diabetes Care 1 January 2021; 44 (Supplement_1): S211–S220. https://doi.org/10.2337/dc21-S015
Download citation file:
toolbar searchThe American Diabetes Association (ADA) “Standards of Medical Care in Diabetes” includes the 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 (https://doi.org/10.2337/dc21-SPPC), 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 (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
Among hospitalized patients, hyperglycemia, hypoglycemia, and glucose variability are associated with adverse outcomes, including death (1–3). Therefore, careful management of inpatients with diabetes has direct and immediate benefits. Hospital management of diabetes is facilitated by preadmission treatment of hyperglycemia in patients having elective procedures, a dedicated inpatient diabetes service applying well-developed standards, and careful transition out of the hospital to prearranged outpatient management. These steps can shorten hospital stays and reduce the need for readmission as well as improve patient outcomes. Some in-depth reviews of hospital care for patients with diabetes have been published (3–5). For older hospitalized patients or for patients in the long-term care facilities, please see Section 12 “Older Adults” (https://doi.org/10.2337/dc21-S012).
High-quality hospital care for diabetes requires standards for care delivery, which are best implemented using structured order sets, and quality assurance for process improvement. Unfortunately, “best practice” protocols, reviews, and guidelines (2–4) are inconsistently implemented within hospitals. To correct this, medical centers striving for optimal inpatient diabetes treatment should establish protocols and structured order sets, which include computerized physician order entry (CPOE).
Initial orders should state the type of diabetes (i.e., type 1, type 2, gestational diabetes mellitus, pancreatic diabetes) when it is known. Because inpatient treatment and discharge planning are more effective if based on preadmission glycemia, an A1C should be measured for all patients with diabetes or hyperglycemia admitted to the hospital if the test has not been performed in the previous 3 months (6–9). In addition, diabetes self-management knowledge and behaviors should be assessed on admission and diabetes self-management education provided, if appropriate. Diabetes self-management education should include appropriate skills needed after discharge, such as medication dosing and administration, glucose monitoring, and recognition and treatment of hypoglycemia (2,3). There is evidence to support preadmission treatment of hyperglycemia in patients scheduled for elective surgery as an effective means of reducing adverse outcomes (10–13).
The National Academy of Medicine recommends CPOE to prevent medication-related errors and to increase efficiency in medication administration (14). A Cochrane review of randomized controlled trials using computerized advice to improve 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 (15). 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 (16,17).
Appropriately trained specialists or specialty teams may reduce length of stay, improve glycemic control, and improve outcomes (10,18,19). In addition, the greater risk of 30-day readmission following hospitalization that has been attributed to diabetes can be reduced, and costs saved, when inpatient care is provided by a specialized diabetes management team (20,21). In a cross-sectional comparison of usual care to management by specialists who reviewed cases and made recommendations solely through the electronic medical record, rates of both hyper- and hypoglycemia were reduced 30–40% by electronic “virtual care” (22). Details of team formation are available in The Joint Commission Standards for programs and from the Society of Hospital Medicine (23,24).
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 diabetes (23), and the Society of Hospital Medicine has a workbook for program development (24).
Hyperglycemia in hospitalized patients is defined as blood glucose levels >140 mg/dL (7.8 mmol/L) (2,3,25). Blood glucose levels persistently above this level should prompt conservative interventions, such as alterations in diet or changes to medications that cause hyperglycemia. An admission A1C value ≥6.5% (48 mmol/mol) suggests that the onset of diabetes preceded hospitalization (see Section 2 “Classification and Diagnosis of Diabetes,” https://doi.org/10.2337/dc21-S002) (2,25). Hypoglycemia in hospitalized patients is categorized by blood glucose concentration and clinical correlates (Table 6.4) (26): Level 1 hypoglycemia is a glucose concentration 54–70 mg/dL (3.0–3.9 mmol/L). Level 2 hypoglycemia is a blood glucose concentration
In a landmark clinical trial, Van den Berghe et al. (27) demonstrated that an intensive intravenous insulin regimen to reach a target glycemic range of 80–110 mg/dL (4.4–6.1 mmol/L) reduced mortality by 40% compared with a standard approach targeting blood glucose of 180–215 mg/dL (10–12 mmol/L) in critically ill patients with recent surgery. This study provided robust evidence that active treatment to lower blood glucose in hospitalized patients had immediate benefits. However, a large, multicenter follow-up study, the Normoglycemia in Intensive Care Evaluation and Survival Using Glucose Algorithm Regulation (NICE-SUGAR) trial (28), led to a reconsideration of the optimal target range for glucose lowering in critical illness. In this trial, critically ill patients randomized to intensive glycemic control (80–110 mg/dL) derived no significant treatment advantage compared with a group with more moderate glycemic targets (140–180 mg/dL [7.8–10.0 mmol/L]) and in fact had slightly but significantly higher mortality (27.5% vs. 25%). The intensively treated group had 10- to 15-fold greater rates of hypoglycemia, which may have contributed to the adverse outcomes noted. The findings from NICE-SUGAR are supported by several meta-analyses, some of which suggest that tight glycemic control increases mortality compared with more moderate glycemic targets and generally causes higher rates of hypoglycemia (29–31). Based on these results, insulin therapy should be initiated for treatment of persistent hyperglycemia ≥180 mg/dL (10.0 mmol/L) and targeted to a glucose range of 140–180 mg/dL (7.8–10.0 mmol/L) for the majority of critically ill patients. Although not as well supported by data from randomized controlled trials, these recommendations have been extended to hospitalized patients without critical illness. More stringent goals, such as 110–140 mg/dL (6.1–7.8 mmol/L), may be appropriate for selected patients (e.g., critically ill postsurgical patients or patients with cardiac surgery), as long as they can be achieved without significant hypoglycemia (32,33). On the other hand, glucose concentrations between 180 mg/dL and 250 mg/dL (10–13.9 mmol/L) may be acceptable in patients with severe comorbidities, and in inpatient care settings where frequent glucose monitoring or close nursing supervision is not feasible. Glycemic levels above 250 mg/dL (13.9 mmol/L) may be acceptable in terminally ill patients with short life expectancy. In these patients, less aggressive insulin regimens to minimize glucosuria, dehydration, and electrolyte disturbances are often more appropriate. Clinical judgment combined with ongoing assessment of clinical status, including changes in the trajectory of glucose measures, illness severity, nutritional status, or concomitant medications that might affect glucose levels (e.g., glucocorticoids), should be incorporated into the day-to-day decisions regarding insulin dosing (34).
In hospitalized patients with diabetes who are eating, bedside glucose monitoring should be performed before meals; in those not eating, glucose monitoring is advised every 4–6 h (2). More frequent bedside blood glucose testing ranging from every 30 min to every 2 h is the required standard for safe use of intravenous insulin. Safety standards for blood glucose monitoring that prohibit the sharing of lancets, other testing materials, and needles are mandatory (35).
The vast majority of hospital glucose monitoring is performed using standard glucose monitors and capillary blood taken from fingersticks, similar to the process used by outpatients for home glucose monitoring (36). Point-of-care (POC) meters are not as accurate or as precise as laboratory glucose analyzers, and capillary blood glucose readings are subject to artifact due to perfusion, edema, anemia/erythrocytosis, and several medications commonly used in the hospital (37). The U.S. Food and Drug Administration (FDA) has established standards for capillary (fingerstick) blood glucose meters used in the ambulatory setting as well as standards to be applied for POC measures in the hospital (37). The balance between analytic requirements (e.g., accuracy, precision, interference) and clinical requirements (rapidity, simplicity, point of care) has not been uniformly resolved (36,38), and most hospitals/medical centers have arrived at their own policies to balance these parameters. It is critically important that devices selected for in-hospital use, and the workflow through which they are applied, have careful analysis of performance and reliability and ongoing quality assessments. Recent studies indicate that POC measures provide adequate information for usual practice, with only rare instances where care has been compromised (39,40). Good practice dictates that any glucose result that does not correlate with the patient's clinical status should be confirmed through measurement of a serum sample in the clinical laboratory.
Real-time continuous glucose monitoring (CGM) provides frequent measurements of interstitial glucose levels as well as direction and magnitude of glucose trends. Even though CGM has theoretical advantages over POC glucose testing in detecting and reducing the incidence of hypoglycemia, it has not been approved by the FDA for inpatient use. Some hospitals with established glucose management teams allow the use of CGM in selected patients on an individual basis, provided both the patients and the glucose management team are well educated in the use of this technology. CGM is not approved for intensive care unit use. For more information on CGM, see Section 7 “Diabetes Technology” (https://doi.org/10.2337/dc21-S007).