Position Statements 15. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2019 American Diabetes Association Diabetes Care 2019 Jan; 42(Supplement 1): S173-S181.https://doi.org/10.2337/dc19-S015 PreviousNext Article Figures & Tables Info & Metrics PDF Abstract 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 the ADA Professional 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 standards, 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 established 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 diabetes self-management education should be provided, if appropriate. Diabetes self-management education should include appropriate skills needed after discharge, such as taking antihyperglycemic medications, monitoring glucose, and recognizing and treating hypoglycemia (2). Physician Order Entry Recommendation 15.2 Insulin should be administered using validated written or computerized protocols that allow for predefined adjustments in the insulin dosage based on glycemic fluctuations. E The National Academy of Medicine recommends CPOE to prevent medication-related errors and to increase efficiency in medication administration (9). 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 (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 the Hospital Recommendation 15.3 When caring for hospitalized patients with diabetes, consider consulting with a specialized diabetes or glucose management team where possible. E Appropriately trained specialists or specialty 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 hospitalization. Specialized diabetes teams caring for patients with diabetes during their hospital stay can improve readmission rates and lower cost of care (15,16). Early evidence suggests that virtual glucose management services may be used to improve glycemic outcomes in hospitalized 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 diabetes (18), and the Society of Hospital Medicine has a workbook for program development (19). GLYCEMIC TARGETS IN HOSPITALIZED PATIENTS Recommendations 15.4 Insulin therapy should be initiated for treatment of persistent hyperglycemia 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 noncritically ill patients. A 15.5 More stringent goals, such as 110–140 mg/dL (6.1–7.8 mmol/L), may be appropriate for selected 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 glucose 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 hypoglycemia 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 discussed more fully below.
