Diabetes Monitor - inpatient management guidelines for people with diabetes

This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.

Identification, Initial Assessment and Management Plan

Goal Statement: To identify all patients with diabetes, document attendant co-morbidities/complications, and determine appropriate therapeutic goals.

	Intervention	Health Care Professional¹	Event/Frequency
Identification	Screening Protocol Diabetes complications can be best avoided through early detection and aggressive glycemic management. In addition, diabetes, whether diagnosed or not, is a significant determinant of a successful in-patient experience. Accordingly, hospital Medical Staffs are encouraged to adopt an appropriate protocol consistent with ADA screening guidelines for all patients >18 years of age.	Admitting or emergency room nurse	On admission, pre-admission, or presentation to the emergency department
The remainder of these guidelines are applicable only to those patients with a confirmed diagnosis of diabetes mellitus.
Initial Assessment and Exam	History of diabetes management and assessment of Standards of Care status (see "Exhibit A - Baseline Diabetes Assessment" in the original guideline document).	Physician/RN/LPN/CDE/RD	On admission/ pre-admission
	Documentation of symptoms of diabetes-related co-morbidities or complications (see "Special Considerations" below).	Physician/RN/LPN/CDE/RD	On admission/ pre-admission
	Physical exam with special emphasis on diabetes-associated and other pertinent findings.	Physician	On admission/ pre-admission
Laboratory Tests	Serum creatinine	Physician	On admission/ pre-admission
	EKG	Physician	On admission/ pre-admission
	Urinalysis	Physician	On admission/ pre-admission
	Plasma glucose (PG)^*	Physician	On admission/ pre-admission or presentation to the emergency department
	A1c	Physician	On admission/ pre-admission unless documented within previous one month
	Lipid profile	Physician	On admission/ pre-admission unless documented within previous one month

¹In consultation with patient/caregiver
^*Blood glucose meters for finger-stick testing use capillary (whole blood) samples, but with few exceptions, are calibrated to display the results in plasma values.
Abbreviations: ADA, American Diabetes Association; RN, registered nurse; LPN, licensed practical nurse; CDE, certified diabetes educator; RD, registered dietitian; EKG, electrocardiogram; A1c, glycated hemoglobin (previously abbreviated HbA_1c)

Special Considerations

Insulin pump. Abrupt or unplanned alteration of pump regimen can result in rapid deterioration of glycemic control, resulting in acute complications (diabetic ketoacidosis or hypoglycemia) and adverse outcomes. Accordingly, any change in regimen should only be ordered by, or in consultation with, the primary diabetes care physician.
Pregnancy. Lack of optimal glycemic control in pregnancy has been shown to cause significant and life-threatening complications to mother and child. Accordingly, consultation^* should be obtained with any admission of a pregnant patient with diabetes.
Coronary and Cerebral Vascular Disease. Early and optimal glycemic control may improve outcomes in patients with acute myocardial infarction, stroke/transient ischemic attack, percutaneous angioplasty, coronary stent placement and coronary artery bypass. Accordingly, any patient admitted with diabetes and one of these diagnoses may benefit from optimal glycemic management and may benefit from consultation.^* See the "Optimal Glycemic Control" section, below, for further information concerning diabetes control.
Infectious Disease. Poorly controlled diabetes has been shown to cause significant impairment of host defense mechanisms in all infections. Accordingly, optimal glycemic control is paramount in the successful management of the infected patient, and consultation^* may be indicated.
Inpatient Surgery. Optimal glycemic control will reduce the incidence of post-operative complications and, therefore, patients with diabetes having inpatient surgery may benefit from consultation.^* See the "Optimal Glycemic Control" section, below, for further information concerning diabetes control.
Pediatrics. The tendency toward labile glucose values and special considerations related to managing diabetes in pediatric patients may result in compromised outcomes and therefore, these patients may benefit from consultation.^*
Diabetic Ketoacidosis. Since diabetic ketoacidosis is a serious condition which requires intensive management, consultation with patient's primary diabetes physician should be considered.

^*In these situations, consultation should be with a physician, who through experience and training, has demonstrated competence in the care of people with diabetes in the acute care setting. This may be the patient's primary care physician.

Optimal Glycemic Control

Goal Statement: To achieve the best glycemic control possible given the clinical situation, but in no event should plasma glucose values be allowed to exceed 150 mg/dL without assessment or intervention. While not always achievable, the ideal values described in the American Diabetes Association (ADA) "Clinical Practice Recommendations" for plasma glucose in the NON-PREGNANT individual are:

	Normal	Goal	Action
Preprandial (mg/dL)	<110	90-130	<90 or >150
Bedtime (mg/dL)	<120	110-150	<110 or >180
These values are generalized to the entire population with diabetes. Some patient populations warrant different treatment goals.

Monitoring	Intervention	Health Care Professional ¹	Event/Frequency
	A1c	Physician	On admission, unless documented within previous one month.
	Bedside plasma glucose monitoring^#, recorded on an appropriate flow sheet^##	Physician	All patients at least 4 times per day unless being orally fed, in which case AC and HS.
	Blood glucose review	Physician	Daily^###
	Alert values reported to physician	Nurse/Lab	PG <60 mg/dL, or per hypoglycemia protocol, >300 mg/dL, or by physician orders.
Maintenance	Reassess/adjust regimen*	Physician	PG <90 mg/dL, >150 mg/dL. This is in accordance with the ADA position statement "Standards of Medical Care for Patients with Diabetes." In order to achieve these parameters (>90 and <150), intravenous insulin infusion is often required in intensive care situations.
	Consultation** with an endocrinologist or a physician with recognized expertise in diabetes inpatient care.	Attending Physician	Should be considered when: PG >300 mg/dL or <70 mg/dL on two occasions within 24 hours (in the absence of diagnostic criteria for items below) despite intervention Major surgery Diabetic ketoacidosis Hyperglycemic, hyperosmolar non-ketotic state Severe or recurrent hypoglycemia or neuroglycopenic symptoms Acute macrovascular events Serious infections or non-healing wounds Should be obtained: Pump therapy Pregnancy
Protocols and Standing Order Sets	Hospital Hypoglycemia Protocol***	Physician/Nurse	PG <60 mg/dL
	Hospital IV Insulin Infusion Protocol	Physician/Nurse	Diabetic ketoacidosis and when ordered for other critically ill patients
	Hospital Perioperative Protocol***	Physician/Nurse	Pre-admission or as soon as possible prior to surgery
	Hospital Insulin Pump Protocol***	Physician/Nurse	Initiation and management

¹In consultation with patient/caregiver
^#Blood glucose meters for finger-stick testing use capillary (whole blood) samples, but with few exceptions are calibrated to display the results in plasma values.
^##In order to assure effective communication of plasma glucose values among all members of the care team, a flow sheet should be developed and incorporated in the medical record for all patients.
^###Adjustment of therapy is indicated if PG >150 mg/dL or <90 mg/dL. Intensive monitoring (>4 x daily) may be required under special circumstances such as post myocardial infarction (MI), total parenteral nutrition (TPN), steroid therapy, etc.
*Regimen includes nutrition, activity, medication and other therapeutic modalities. If sliding scales are utilized, it is recommended that a hospital protocol be developed.
**In these situations, consultation should be with a physician who, through experience and training, has demonstrated competence in the care of people with diabetes in the acute care setting. This may be the primary care physician.
***Hospital medical staffs are encouraged to develop and implement appropriate protocols for people with diabetes.
Abbreviations: A1c, glycated hemoglobin (previously abbreviated HbA_1c ); AC, before meals; HS, at bedtime; PG, plasma glucose; IV, intravenous

Medical Nutrition Therapy

Goal Statement: To optimize metabolic status, the nutritional needs of every person with diabetes admitted to the hospital will be assessed. A nutritional plan will be developed by a registered dietitian for approval by the physician.

Establishment, Monitoring and Maintenance	Intervention	Health Care Professional¹	Event/Frequency
	Initial specific nutritional plan for the patient with diabetes	Physician and RD	On admission
	Comprehensive nutritional assessment	RD and Physician	Prior to or within 24 hours of admission
	Reassessment/regimen adjustment	RD and Physician	Daily or as indicated
	Discharge nutritional plan	RD and Physician	Prior to discharge
	Discharge instructions and follow-up plan	RD, CDE, RN, Case Manager, or Physician	At discharge

¹In consultation with patient/caregiver
Abbreviations: RD, registered dietitian; CDE, certified diabetes educator; RN, registered nurse

Education and Discharge Planning

Goal Statement: To identify and correct both knowledge and self-care skills deficiencies and to establish an optimal transition into the post-hospital management of the patient.

Assessment	Intervention	Health Care Professional¹	Event/Frequency
Assessment	Baseline diabetes assessment*	Physician, RN, CDE, or RD; with patient/caregiver	On admission
Patient Management Plan	Development of patient education plan to include, at a minimum, diabetes survival skills and initiation/arrangement of outpatient plan to address identified deficiencies*	Physician, RN, CDE, and patient and/or caregiver	Throughout hospital stay
Patient/Caregiver Skills Demonstration	Successful demonstration of patient glucose monitoring	RN, CDE, LPN	Minimum of two times prior to discharge
	Successful demonstration of administration of insulin, if indicated	RN, CDE, LPN	Minimum of two times prior to discharge
	Successful demonstration of foot inspection	RN, CDE, LPN	One time prior to discharge
Diabetes Follow-up	Patient standards of care**** status and outpatient education plan given to patient and reported to primary diabetes provider	Physician, RN, CDE, or RD; with patient/caregiver	Prior to discharge
Diabetes Follow-up	Follow-up diabetes management appointment recommended or arranged	Physician, RN, CDE or RD; with patient/caregiver	Prior to discharge

¹In consultation with patient/caregiver
*See Exhibit A - "Baseline Diabetes Assessment" in the original guideline document
**See Exhibit B - "Diabetes Survival Skills" in the original guideline document
***See Exhibit C - "National Standards for Diabetes Self-Management Education Programs, Curriculum Content Areas" in the original guideline document
**** See Exhibit D - "Standards of Care" in the original guideline document
Abbreviations: RN, registered nurse; CDE, certified diabetes educator; RD, registered dietitian; LPN, licensed practical nurse

Optimal Metabolic Control For Pregnancy

(Gestational Diabetes Mellitus*,Type 1 Diabetes and Pregnancy**, Type 2 Diabetes and Pregnancy**)

Goal Statement: To achieve and maintain euglycemia before and throughout pregnancy. Euglycemia is defined as: fasting plasma glucose 65-90 mg/dL; One hour postprandial plasma glucose <140 mg/dL; A1c <6.5% during all trimesters

Monitoring	Intervention	Health Care Professional ^1,2	Event/Frequency
	A1c with normal range in pregnancy established	Physician	On admission
	Finger stick plasma glucose		Before and one hour after each meal, at bedtime, and at 3:00 am
	Plasma glucose review		Daily^#
	Alert values reported to physician		PG <55 mg/dL, or >150 mg/dL
Maintenance	Reassess/adjust regimen	Physician	Pre-prandial <60 mg/dL or >90 mg/dL. One hour after meals <100 mg/dL or >120 mg/dL
Protocols and Standing Order Sets	GDM, Diet Controlled	Physician/Nurse	On admission
	GDM, Insulin Requiring***	Physician/Nurse	On admission
	Type 1 Diabetes and Pregnancy***	Physician/Nurse	On admission
	Type 2 Diabetes and Pregnancy***	Physician/Nurse	On admission
	Labor and Delivery for Types 1 and 2***	Physician/Nurse	On admission
	Labor and Delivery for GDM***	Physician/Nurse	On admission
	Post-Partum Care and Insulin Dosing*** For nursing mothers For non-nursing mothers	Physician/Nurse	Immediately after delivery
	Neonatal Care for Infants of Diabetic Mothers	Physician/Nurse	Immediately after delivery
	Hyperemesis Gravidarum and Diabetes	Physician/Nurse	On admission

¹In consultation with patient/caregiver
²Consultation with an endocrinologist/diabetologist and/or a high-risk obstetrician is strongly recommended for admission of a pregnant diabetic.
#To assure effective communication of plasma glucose values among all members of the care team, a flow sheet should be developed and incorporated in the medical record for all patients.
*Gestational diabetes is diagnosed when two or more of the venous plasma values following a 100 gram glucose load (after an overnight fast of between 8-14 hours and at least three days of unrestricted diet of over 150 grams of carbohydrates) are exceeded: Fasting 95 mg/dL; One hour 180 mg/dL; Two hours 155 mg/dL; Three hours 140 mg/dL
**Ideally, plasma glucose control should be established before pregnancy and is defined as A1c <4 standard deviations (SDs) above the mean of a normal population (using Diabetes Control and Complications Trial [DCCT] normal range of <6.01%:4SD=A1c <7.0%)
***Protocol should include specific instructions for management of hypoglycemia.

Abbreviations: A1c, glycated hemoglobin (previously abbreviated HbA_1c); PG, plasma glucose; GDM, gestational diabetes mellitus