Australian Diabetes Society (ADS) produced the document ‘Guidelines for Routine Glucose Control in Hospital 2012‘
The aim of this document is to provide guidance for the management of hyperglycaemia in a range of hospital situations.
As a people living with diabetes you an use this guide to ask about your care when admitted to hospital, or as a part of your sick day management plan (in the event of an urgent hospital admission).
The ADS has focused on the management of hyperglycaemia in people with myocardial infarction and stroke, on general hospital wards, and other matters they may be admitted to hospital with.
The optimal means of achieving tight blood glucose management, the role of the specialist inpatient diabetes team, inpatient management of insulin pump therapy, and general measures for diabetes management have also been examined.
The document also provides guidance for the follow‐up of people who have been newly discovered hyperglycaemia.
The recommendations were based on evidence obtained from systematic reviews where trials had been performed; otherwise they were made by consensus.
What Glucose Target Should be Aimed for in Acute Myocardial Infarction (heart attack)?
Studies indicate that persistent hyperglycaemia, even if mild, is also associated with increased mortality following myocardial infarction.
Recommendations and Practice Points
- Patients admitted to hospital with myocardial infarction who have hyperglycaemia, should be treated to achieve and maintain glucose levels less than 10 mmol/L.
- Hypoglycaemia must be avoided. It would be prudent to avoid treatment which lowers the glucose below 5 mmol/L.
- Insulin infusion therapy may allow for tighter targets but this requires frequent monitoring and high level staff training.
What Glucose Target Should be Aimed for in Acute Stroke
Recommendations and Practice Points
- Patients admitted to hospital with acute thrombotic stroke who have hyperglycaemia, should be treated to achieve and maintain glucose levels less than 10 mmol/L.
- Hypoglycaemia must be avoided, and therefore it would be prudent to avoid treatment which lowers the glucose below 5 mmol/L.
What are Appropriate Glucose Targets for Patients in General Hospital Wards?
Recommendations and Practice Points
- Most patients in general hospital wards with hyperglycaemia should be treated to achieve and maintain glucose levels less than 10 mmol/L.
- Hypoglycaemia must be avoided. It would be prudent to avoid treatment which lowers the glucose below 5 mmol/L.
- To achieve tight glucose control safely, frequent glucose monitoring is recommended
How is Steroid‐Induced Hyperglycaemia Best Managed?
Recommendations and Practice Points
- In patients receiving glucocorticoids, undiagnosed diabetes should be excluded. Those free of diabetes should be screened for the development of hyperglycaemia by random blood glucose monitoring performed in the afternoon following morning administration of GC.
- Hyperglycaemia is best managed with insulin: basal insulin as isophane type insulin, and rapid acting analogue with meals as required.
- In individuals already on insulin the likely need for increased insulin should be recognised. Dose requirements need to be individualised and require daily review.
What is the Optimal Means of Achieving and Maintaining Glycaemic Control in Hospitalised Patients who are not Critically Ill?
Recommendations and Practice Points
- Sliding scale insulin should not be used to optimise glucose control in the inpatient general medical or surgical setting.
- Oral hypoglycaemic agents or pre‐mixed insulin can be used in certain stable hospitalised patients who are eating regularly. Supplemental insulin should be written up in addition.
- Insulin therapy in hospitalised patients should otherwise consist of a basal insulin, prandial and supplemental insulin. **Effective use of basal bolus insulin requires frequent and regular blood glucose monitoring (at least 4 and preferably 6‐8 times daily)
How Should Patients on Insulin Pump Therapy be Managed in Hospital?
Recommendations and Practice Points
- In general, CSII should be continued in hospital where the patient can competently and safely self-manage the pump and self‐dosing.
- Details of pump therapy should be documented, and supported by the endocrine team
- CSII may be continued for short operative procedures if those responsible for the patient’s intraoperative care are comfortable with its use.
What is the Role of a Specialist Inpatient Diabetes Team?
Consultant Service.
The traditional hospital model of care, whereby specialised diabetes services are invited, at the discretion of the admitting team, to assist with specific patients’ diabetes management.
There is no evidence that improving this model has resulted in any substantial benefits. Anecdotal evidence suggests that this is akin to “shutting the gate once the horse has bolted”.
Systematic Hospital‐wide Diabetes Programme
These programmes aim to improve the identification of patients with diabetes and to enhance the diabetes management skills of all staff, by education and implementation of diabetes management and prescription guidelines. The responsibility of managing the patient’s diabetes remains with the admitting team.
The evidence supporting such an institution‐wide approach in improving diabetes‐related outcomes is limited to one comparative study162 which demonstrated a reduction in length of stay of 1.8 days for patients with primary diabetes following the intervention.
Specialist Diabetes Inpatient Management Team
This involves a multidisciplinary team approach, with the role of the Inpatient Diabetes Management Team varying from an advisory function to active management of the patient’s diabetes, for all patients with diabetes and usually commences at the time of the patient’s admission.
Several comparative trials (4‐9) have shown reductions in ALOS of 0.26‐5.6 days following intervention by an inpatient diabetes management team, primarily involving a specialist diabetes nurse (some with prescribing capabilities).
# Diabetes inpatient specialist nurse service: Mean excess bed days for diabetes admissions reduced from 1.9 days to 1.2 days after introduction of the service.
# Diabetes Specialist Nurse with prescribing rights: Reduction in medication errors from median 6 to 4 (p<0.01); Reduction in Length Of Stay from median from 9 to 7 days (p<0.05)
#Endocrinologist, diabetes nurse specialist, junior doctor: Reduction in average Length Of Stay for all patients with diabetes from 9.39 to 3.76 days.
*****Want to get out of hospital asap – ask to see a member of the diabetes inpatient management team*****
For more detail in this document go HERE
How has your experience of hospital admissions effected the way you manage your diabetes at home? Or during subsequent hospital admissions?
Kind Regards,
David
Diabetes Educator @ Diabetes Counselling Online
