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Hyperglycemia in the Hospital
Hyperglycemia in the Hospital -- Posted by Gumbo on 03-06-05 06:48
Hyperglycemia in the Hospital
This review will focus on the rationale and methodology for management of
hospital hyperglycemia under conditions that do not require intravenous
insulin infusion.
For many years, tradition held that hospitalization was not the time in the
life of a patient with diabetes to focus on glycemic control. The
complications of diabetes were divided into 1) acute metabolic emergencies
requiring patient stabilization rather than perfection of glycemic control
and 2) chronic tissue complications, which had required months or years to
evolve. It was thought that safety considerations dictated the prudence of
avoiding hospital hypoglycemia.
Nevertheless, adverse hospital outcomes have been linked to hyperglycemia.
These include nosocomial infection, sepsis, cardiac mortality after
myocardial infarction or cardiac surgery, atrial fibrillation after cardiac
surgery, increased infarct size after stroke, acute graft rejection after
transplantation, "unit" neuropathy, transfusion requirement and acute renal
failure in critical care unit patients, prolongation of stay, and increased
cost.1-21 Some of these outcomes, being multifactorial in etiology and not
readily classifiable as a manifestation of microvascular or macro-vascular
disease, were not linked intuitively to specific diabetes treatment actions.
In fact, it took randomized, controlled trials to establish the
relationship.
The revolution in present-day thinking about the importance of inpatient
glycemic control has occurred because of the findings of a large and
long-running cardiac surgery series3,5,14 and because of the convincing
evidence of randomized, controlled trials demonstrating, first, the causal
nature of the relationship between hyperglycemia and some of the outcomes
listed above, and, second, the ability of intensive insulin management to
reduce those adverse outcomes.22-27 (Readers are referred to the article by
Goldberg and Inzucchi in this issue of Diabetes Spectrum, p. 28-33.)
The strongest evidence for hospital outcomes advantages was obtained,
without significant complications from hypoglycemia, during and after the
use of intravenous insulin infusion under conditions of intensive
monitoring. For general medical conditions treated in hospital wards other
than intensive care units, similar outcomes data do not exist. It will be
necessary to show, from randomized trials prospectively conducted outside of
the intensive care unit setting, that specific benefits will result from
intensive subcutaneous insulin management, without prohibitive risk from
hypoglycemia. It is necessary to define blood glucose (BG) targets and to
determine whether there is any glycemic threshold, other than the upper
limit of normal, above which those benefits are jeopardized. Pending the
results of such research, upper limits of glycemic targets intended to
provide clinicians with guidelines for promoting improved outcomes have been
recommended (Table 1).28,29
Mechanisms of Hospital Hyperglycemia and Protection by Glycemic Control or
Insulin
Conditions of hospitalization, such as trauma, hemorrhage, burns, hypoxia,
infections, sepsis, or shock, may induce both insulin resistance and
relative insulin secretory defect. Both peripheral and hepatic sites of
insulin resistance have been implicated. The consequences include increased
muscle protein degradation, decreased peripheral glucose disposal, lipolysis
resulting in increased circulating nonesterified fatty acids,
hyperlactatemia, and increased hepatic glucose output. Mechanisms of the
observed defects of insulin signaling and relative ß-cell suppression during
acute illness are the subject of active research.30
The targets for protective action of insulin in the hospital setting
prominently include the heart, the endothelium (vasodilatory action,
protection against vessel wall inflammatory processes), the inflammatory
pathway, the coagulation pathway, host defenses against infection, and the
nutritional status of the patient.
Protection may be conferred in part by metabolic control (correction of
hyperglycemia, reduction of circulating nonesterified fatty acids, reduction
of lactate, reversal of proteolysis, and protection against the downstream
nonmetabolic consequences of these abnormalities). Protection also may be
conferred by other direct or indirect nonmetabolic effects of insulin itself
(nitric oxide-mediated improvement of endothelial function; regulation of
nuclear factor-?B; inhibition of the production of harmful reactive oxygen
species; regulation of the transcription of proinflammatory genes, adhesion
molecules, and chemokines; and suppression of early growth response gene-1,
plasminogen activator inhibitor 1, and matrix metalloproteinases).30-33
Deciding on a Treatment Plan
One of the first challenges on admission is to recognize the presence of
diabetes or risk for hospital hyperglycemia by patient history and
examination and by measurements of BG and potentially hemoglobin A1c
(A1C).34 Another challenge is the need for the admitting team to identify
type 1 diabetes and record the classification.28
The timing of BG monitoring should be planned with consideration of the
pattern of exposure to carbohydrate and antihyperglycemic treatment (Figure
1). The purpose of monitoring is to determine a pattern that might require
initiation or revision of daily therapy with antihyperglycemic medication
(for example, during pregnancy postprandial testing should be included), to
detect hypoglycemia, and to provide BG measurements at the times of day when
correction doses might best be used.
Under conditions of hospitalization, metformin commonly is contraindicated.
In general, oral agents do not provide the flexibility necessary to gain
control rapidly. Sometimes oral agents are stopped on admission but are
reintroduced as a patient approaches discharge.
Patients previously taking insulin temporarily may have a new total daily
dose (TDD) requirement. In contrast to the ambulatory pattern of insulin
requirement consisting of a fairly continuous basal demand with discrete
prandial elevations, the hospital pattern of insulin requirement may reflect
continuous delivery or interruption of nutrition. The best course of action
for demonstrable hyperglycemia usually is to plan a program of scheduled
insulin appropriate to the specific conditions of hospitalization.28
Insulin for Specific Conditions of Hospitalization
Scheduled (programmed) insulin
Specific insulin products are not uniquely identified as replacement for
particular physiological insulin functions (basal or nutritional). However,
for purposes of calculation of an initial TDD of insulin and establishment
of a pattern of delivery, it is useful to think of therapy as having the
following components: basal, nutritional, and correction-dose insulin. To
match the anticipated and changing patterns of insulin requirement under
conditions of hospitalization, providers have a palette of insulins and
insulin analogs, each having a characteristic peak and duration of action
when given subcutaneously, with which to "paint" the day (Figure 1).
Rapid-acting analog therapy (lispro, aspart) is efficacious for coverage of
prandial needs for patients eating discrete meals or for correction of
hyperglycemia. For acute severe hyperglycemia, BG monitoring and
subcutaneous injection of rapid-acting insulin analog can be ordered every
2-2.5 hours until BG correction occurs. Given every 1-2 hours, rapid-acting
analog has been used in the treatment of ketoacidosis.35 If perfusion of
subcutaneous sites is impaired, however, after repeated doses of
subcutaneous insulin, there is a danger of delayed effect occurring beyond
the expected time frame of action, with consequent late hypoglycemia.
Rapid-acting analog therapy is not well suited for coverage of basal
requirements or insulin requirements resulting from continuous delivery of
nutritional support or intravenous dextrose.
Long-acting peakless analog (glargine) administered once daily for patients
having type 1 diabetes ensures against inadvertent omission of needed basal
insulin coverage. A correctly established dose of glargine providing basal
coverage may be safely administered in type 1 diabetes, despite NPO (nothing
by mouth) status.36 With realization that requirements for exogenous insulin
may have been inflated because of overnutrition and may vanish during
prolonged NPO status, a safe minimum dose estimating true basal requirements
still may be replaced as glargine insulin during NPO status in type 2
diabetes. Because nutrition or dextrose suddenly may be interrupted, as a
safety precaution against hypoglycemia in unstable hospitalized patients,
the doses of glargine generally should not be titrated to meet nutritional
requirements, but rather, they should meet only the estimated basal insulin
requirement. Glargine is not recommended during pregnancy.
NPH and subcutaneous regular insulin are especially useful for patients
whose carbohydrate exposure is not delivered as discrete meals. When insulin
is required, a regimen of mixed NPH and regular insulin given every 6-8
hours provides excellent coverage for NPO status, intravenous dextrose, or
continuous enterai feedings. NPH and subcutaneous regular insulin can
supplement intravenous insulin coverage used as an additive with total
parenteral nutrition. NPH and subcutaneous regular insulin are well suited
to cover transitional meal plans and corticosteroid therapy.
Intermediate-acting insulin and regular insulin or rapid-acting analog also
can be used to cover normal diet with discrete meals. NPH insulin is
preferred to glargine for basal coverage during use of multiple daily
injection therapy in pregnancy.
Starting doses of insulin
In type 1 diabetes, true basal requirements for exogenous insulin are
absolute. Generally, the basal insulin requirement is ~ 40-50% of the
preadmission TDD of insulin, or (in the absence of renal failure or other
conditions that reduce insulin requirement) a conservative low estimate is ~
0.25 units/kg.
In type 2 diabetes, the apparent. requirement for exogenous basal insulin
may vanish during prolonged NPO status. However, a safe minimum starting
point (in the absence of renal failure), which would be tolerated as
replacement for endogenous basal insulin production even if the requirement
should trend downward, is ~ 0.15 units/kg of actual body weight.
For patients who are eating normal meals, there is a nutritional insulin
requirement approximately equal to the basal requirement. For patients
receiving intravenous dextrose or nutritional support, the nutritional
requirement can be initially estimated at ~ 1 unit/10 g carbohydrate, an
amount that often requires subsequent upward revision.37
The starting TDD of insulin can be envisioned as the sum of the basal and
nutritional requirements, calculated as discussed above.
Correction doses, "hold" orders, and daily revision of scheduled insulin
"Sliding scale insulin" as monotherapy generally is ineffective and may be
harmful.38-40 Correction doses (supplements) of rapid-acting analog or
regular insulin should be proportionate to the TDD insulin requirement or,
if that requirement is unknown, then correction doses should be
proportionate to an estimate of TDD requirement based on assumptions about
typical requirements for a given body weight.41,42 Over several days, use of
a dose-finding process for the scheduled insulin requirement reduces
reliance on correction doses.
Except for basal insulin in type 1 diabetes, orders might include a
provision for nursing staff to withhold or reduce doses of scheduled insulin
in the event of downward trending of BG or interruption of carbohydrate
exposure.
The dose of scheduled insulin should be recalculated daily based on BG
response, the amount of insulin actually administered on the previous day,
and the changing condition of the patient. Review of charted doses is
necessary to discover withholding of ordered doses of scheduled insulin or
use of correction doses. For both type 1 and type 2 diabetes, it is an
important precaution to reduce the TDD of scheduled insulin in case of
downward trending of BG or development of factors that might predispose to
hypoglycemia, such as renal or hepatic failure or resolution of stress- or
drug-related hyperglycemia.42
Consistent carbohydrate diets
For patients who are eating and receiving fixed doses of antihyperglycemic
medication, an order for a consistent carbohydrate diet enhances the ability
of the caregiver to achieve predictable results.43,44
Patient self-management of diabetes in the hospital
Unless they prefer to have their doses of insulin and meal plans assigned,
competent patients who are experienced in self-management generally should
continue to determine their dietary selections and administer their insulin
in the hospital.45 A multidisciplinary effort is necessary to establish a
safe policy on inpatient diabetes selfmanagement. (Readers are referred to
the article by Nettles in this issue of Diabetes Spectrum, p. 44-48).
Hypoglycemia prevention
In one study, 45% of episodes of hospital hypoglycemia resulted from
triggering events, such as sudden change of caloric exposure, and 39%
resulted from inappropriate adjustment of insulin dose in the presence of
medical conditions predisposing to hypoglycemia or previous episodes of
hypoglycemia. When there is poor perfusion of subcutaneous injection sites,
as with hypotension, use of pressors, or edema, delayed snowballing of
repeated doses of subcutaneous insulin can cause hypoglycemia. Because these
situations are recognizable in advance, iatrogenic hospital hypoglycemia
appears to be largely predictable and frequently should be preventable by
fairly simple measures.46,47 (Readers are referred to the article by Tomky
in this issue of Diabetes Spectrum, p. 39-44, for nursing precautions.)
Discharge planning
The question may be raised of whether hospital hyperglycemia in fact
signifies the presence of diabetes. An A1C of > 6% drawn at admission
suggests diabetes, whereas an AlC < 5.2% suggests nondiabetes.34 In
outpatient follow-up, the diagnosis should be established by BG criteria.48
Hospitalization may provide an ideal opportunity to introduce patients with
diabetes to strategies that might improve their preadmission control or
reduce hypoglycemia, such as the addition of basal insulin to oral
agents49,50 or intensification from use of regular and intermediate-acting
insulin to multiple daily injections of insulin using a rapid-acting analog
and basal insulin.51-55 Outpatient follow-up over several visits with a
diabetes educator and dietitian is necessary to establish the skill of
matching prandial insulin to variable carbohydrate intake. This strategy
(advanced carbohydrate counting), at least in type 1 diabetes, yields
results superior to fixed-dose use of prandial insulin.56
Education of caregivers
One barrier to improved diabetes care in the hospital, shown by Bernard et
al.,57 is that most trainee physicians do not think that additional training
in diabetes care is needed. In that study, resident physicians felt that
insufficiency of time was a greater barrier than deficiency of training. The
authors hypothesized that the difficulties with residents' diabetes
practices could result from a lack of knowledge and experience on the part
of the supervising physicians. While this study was conducted in an
ambulatory care setting, the same conclusions could be extrapolated to the
inpatient experience.
Baldwin et al.58 explored this issue further by designing a systematic
approach to educate residents in inpatient insulin management. Residents
were educated regarding management of hyperglycemia without using sliding
scale insulin, which is ubiquitous in most inpatient settings and oftentimes
is the sole means of blood glucose management. An endocrinologist supervised
a basal-bolus regimen in all patients treated with insulin. A team
consisting of two residents managed BG levels for all of the team's patients
and rounded twice daily with the supervising endocrinologist.
At the end of the rotation, all house officers felt confident in inpatient
diabetes management without using a sliding scale. There was a significant
decrease in the length of stay compared to a risk-matched control group, and
the use of a sliding scale was effectively abolished in this particular
training program. Interestingly, the use of a sliding scale on the surgical
services not involved in this study also declined by 43%.
This study exemplifies how intensive education, particularly for fellows,
residents, and interns, can go a long way in improving glycemic control and
achieving overall improved outcomes for diabetic patients. In the future, it
would be helpful to have more data regarding the efficacy of different
teaching models for education of house staff and other health care providers
involved in diabetes management.
Several methods of providing staff nurses with education about diabetes
management have been reported in the literature. Adams and Cook59 compared
the diabetes nursing care of two groups of home health agency nurses: those
with a diabetes educator and those without. They found that although both
groups scored similarly on a diabetes knowledge test, the nurses with the
diabetes clinical nurse specialist scored higher in their care of diabetes
patients on a nursing care intervention tool. The authors speculated that
this resulted from the orientation modules, nursing care plans, and teaching
tools provided to the staff nurses by the diabetes clinical nurse
specialist.
Self-directed learning about diabetes was the approach to educating staff
nurses used by Dunning.60 The author developed a nursing care manual for the
most frequent admission diagnoses for diabetes patients at a major teaching
hospital. This manual was a unit resource for staff nurses. The manual was
designed to improve the knowledge of nurses caring for diabetic patients and
to be used as a springboard for developing nursing policies and standards
for the nursing care of patients with diabetes.
Parker et al.61 studied the impact of a diabetes education program on
improving nurses' diabetes knowledge and changing nurse behavior in
long-term care facilities. Nurses from two long-term care facilities
participated in a multisession education program on diabetes treatment.
Diabetes knowledge was assessed using both a preand postprogram test.
Comparison was made with a control group of nurses from two other long-term
care facilities who did not attend the education program. The nurses
attending the education program had a significant increase in their
postprogram knowledge score compared to those in the control group. However,
a chart review revealed that there was no significant improvement
postprogram in diabetes nursing care behaviors, such as giving insulin in
the abdomen or giving carbohydrate after low blood glucose. The authors
postulated that the lack of behavior change was because there was no
opportunity for re-enforcement sessions and no contact with a diabetes nurse
educator.
The findings of Parker et al. were supported by the work of Asselin.62 She
found that experienced hospital staff nurses primarily use new knowledge
from unit-based resources to change their clinical practice. In only 1 of 29
examples given by these nurses was nursing practice changed by knowledge
gained from attending a formal continuing education program. Asselin
recommended that nursing staff development focus on unit-based resources and
unit-based trainers. In addition, a network of multidisciplinary resource
personnel and unitbased computer access to disease-specific knowledge bases
would provide further information. A regular staff member from each unit
thus might receive additional training and become a champion for diabetes to
promulgate the spread of knowledge among his or her peers.
A nursing clinical practice group can be defined as a group of nurses in the
same nursing specialty at an institution who meet periodically to review
their current nursing practice as it relates to standards of nursing care,
institutional policies and procedures, and evidence-based practice. Clinical
practice groups offer an avenue for communicating new ideas and new
requirements and challenging the status quo. They allow for the use of
critical thinking skills to evaluate current and future clinical practices
and to discuss ways to improve nursing care for patients with specific dis
eases or conditions. This venue supports both novice and experienced nurses'
perspectives on patient care. It enhances the likelihood that both the
organization and its patients will benefit from performance improvement
measures in order to provide the best diabetes care and education possible.
Clinical practice groups are an excellent way to enhance clinical nursing
practice.
Organization, Safety, Quality, and Systems Development
Who should be the caregiver?
The specialty training of caregivers may influence the hospital course for
patients with diabetes. One study of diabetic ketoacidosis (DKA) by Levetan
et al.63 compared outcomes in patients cared for by generalists to those
cared for by endocrinologists. The endocrinologist-treated group had a
significantly lower readmission rate for DKA as well as a significantly
shorter length of stay. Endocrinologists treated patients more
cost-effectively than generalists, keeping their costs to almost half of
their generalist counterparts. This savings resulted mainly from avoidance
of unnecessary imaging and laboratory studies by those unfamiliar with DKA.
In another study by Levetan et al.,64 the length of stay for patients with
diabetes was shorter by 35% for those cared for by a diabetes consult team,
which was a statistically significant difference.
Koproski et al.65 randomly assigned 179 patients to either usual care or
care by a diabetes team consisting of a nurse educator and an
endocrinologist. The diabetes team intervention reduced the length of
hospital stay, improved glycemic control, and reduced the rate of recurrent
hospitalizations when compared to usual care. Clearly, the multidisciplinary
diabetes care team approach is more effective than usual care, and there is
some evidence that specialized nursing care contributes to the difference.
Davies et al.66 showed that diabetic patients randomized to a diabetes
specialist nursing service had shorter lengths of stay and lower costs of
care. Patient satisfaction and knowledge of disease was superior in the
intervention group.
Safety and quality
Safety and quality can be best assured by a multidisciplinary effort
supported by hospital administration and diabetes experts and involving
quality assurance personnel, nurses, dietitians, pharmacists, the
point-of-care testing program, clinical informatics, physicians, and members
of other departments.1,67-71
Managing complexity with a single signature: paper protocols and electronic
health records
If hospital systems present impediments to comprehensive care plans, even
the most well-intentioned and knowledgeable caregivers, defeated by the
pressure of time and taking the path of least resistance, may order an
oversimplified and ineffective plan. In contrast, if the hospital offers
standardized order sets, then practitioners may easily implement a complex
and multifaceted individualized care plan by entering a few check marks and
numbers and a single signature.41,42,72 Whether the practitioner 1) uses
knowledge-embedded paper order sets or 2) has access to a robust integrated
electronic health record that incorporates a clinical data repository,
clinical decision support and rules, and computerized provider order
entry,73 the resulting plan of care must reflect the necessary complexity of
detailed diabetes care.
Computerized provider order entry for diabetes is in its infancy.
Nevertheless, computer prompting has been shown to reduce reliance on
sliding scale monotherapy and increase the use of scheduled insulin.74
Computerized systems must make it convenient for users to select and
implement the components of a comprehensive diabetes care plan under
protocols or algorithms (Table 2). The design of any paper-based or
computerized clinical order set based on accepted algorithms or protocols
must: 1) query the electronic database or provider about weight, age,
pregnancy, and risk for hypoglycemia; 2) encompass the desired input and
output; 3) provide options for user override of defaults and for free text
entries; 4) have flexibility to encompass future change; 5) accept input
from diabetes experts and users and 6) ensure transparency of algorithms for
review by the users.
Conclusion
Initiatives to intensify the treatment of hospital hyperglycemia result in
improved patient outcomes and cost reductions.
How can hospitals move in the direction of intensifying treatment? One part
of the answer is the participation of diabetes experts and champions, not
only in the direct care of patients, but also in the education of
physicians, nursing staff, dietitians, pharmacists, and others.
Another part of the solution, under enlightened hospital leadership, is the
multidisciplinary design of systems that support improvements in hospital
management of hyperglycemia. Such efforts potentially would affect screening
for hyperglycemia; knowledge of appropriate glycemic targets; recognition of
hyperglycemia as an indication for monitoring and treatment; spread of the
use of intravenous insulin infusion; recognition and interception of unsafe
situations leading potentially to hypoglycemia or ketosis; preservation of
basal insulin regimens for type 1 diabetes; standardization of approaches to
prevent hypoglycemia; facilitation of inpatient diabetes self-management for
experienced and competent patients; elimination of sliding scale
monotherapy; generation of effective orders for scheduled subcutaneous
insulin therapy; creation of order sets and implementation of computerized
clinical systems that facilitate regimen selection, intensification, and
daily revision of insulin therapy; and appropriate patient education and
discharge planning.
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