Diabetes Care in the Hospital 2018 Standards from the ADA
At St. Dominic we follow the ADA Standards of Care.
- 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 basal plus bolus correction insulin regimen, with the addition of nutritional insulin in patients who have good nutritional intake, is the preferred treatment for noncritically ill patients.
- Prolonged* use of sliding scale insulin in the inpatient hospital setting is strongly discouraged
*poorly controlled blood glucose over 48 hours with sole use of correctly dose only
The use of subcutaneous rapid- or short-acting insulin before meals or every 4–6 h if no meals are given or if the patient is receiving continuous enteral/parenteral nutrition is indicated to correct hyperglycemia (2). Basal insulin or a basal plus bolus correction insulin regimen is the preferred treatment for noncritically ill patients with poor oral intake or those who are taking nothing by mouth (NPO). An insulin regimen with basal, nutritional, and correction components is the preferred treatment for noncritically ill hospitalized patients with good nutritional intake.
If the patient is eating, insulin injections should align with meals. In such instances, POC glucose testing should be performed immediately before meals. If oral intake is poor, a safer procedure is to administer the rapid-acting insulin immediately after the patient eats or to count the carbohydrates and cover the amount ingested (30).
A randomized controlled trial has shown that basal-bolus treatment improved glycemic control and reduced hospital complications compared with sliding scale insulin in general surgery patients with type 2 diabetes (31). Prolonged sole use of sliding scale insulin in the inpatient hospital setting is strongly discouraged
Glucocorticoid type and duration of action must be considered in determining insulin treatment regimens. Once-a-day, short-acting glucocorticoids such as prednisone peak in about 4 to 8 h (59), so coverage with intermediate-acting (NPH) insulin may be sufficient. For long-acting glucocorticoids such as dexamethasone or multidose or continuous glucocorticoid use, long-acting insulin may be used (26,58). For higher doses of glucocorticoids, increasing doses of prandial and supplemental insulin may be needed in addition to basal insulin (60). Whatever orders are started, adjustments based on anticipated changes in glucocorticoid dosing and POC glucose test results are critical
Transition from the Acute Setting
An outpatient follow-up visit with the primary care provider, endocrinologist, or diabetes educator within 1 month of discharge is advised for all patients having hyperglycemia in the hospital. If glycemic medications are changed or glucose control is not optimal at discharge, an earlier appointment (in 1–2 weeks) is preferred, and frequent contact may be needed to avoid hyperglycemia and hypoglycemia.
All information directly from Chapter 14. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes -2018
American Diabetes Association
Diabetes Care 2018 Jan; 41(Supplement 1): S144-S151. https://doi.org/10.2337/dc18-S014