Dha Hospital Standards

[Nella Mcnairy]

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16.2 Institutions should implement protocols using validated written or computerized provider order entry sets for management of dysglycemia in the hospital (including emergency department, intensive care unit [ICU] and non-ICU wards, gynecology-obstetrics/delivery units, dialysis suites, and behavioral health units) that allow for a personalized approach, including glucose monitoring, insulin and/or noninsulin therapy, hypoglycemia management, diabetes self-management education, nutrition recommendations, and transitions of care. B

The National Academy of Medicine recommends CPOE to prevent medication-related errors and to increase medication administration efficiency (12). Systematic reviews of randomized controlled trials using computerized advice to improve glycemic outcomes in the hospital found significant improvement in the percentage of time individuals spent in the glycemic goal range, lower mean blood glucose levels, and no increase in hypoglycemia (13). Where feasible, there should be structured order sets that provide computerized guidance for glycemic management. Insulin dosing algorithms using machine learning and data in the electronic health record (EHR) currently in development show promise for predicting insulin requirements during hospitalization (14).

16.3 When caring for hospitalized people with diabetes (with an existing or new diagnosis) or stress hyperglycemia, consult with a specialized diabetes or glucose management team when accessible. B

16.6 In people with diabetes using a personal continuous glucose monitoring (CGM) device, the use of CGM should be continued during hospitalization if clinically appropriate, with confirmatory point-of-care (POC) glucose measurements for insulin dosing decisions and hypoglycemia assessment, if resources and training are available, and according to an institutional protocol. B

16.7 For people with diabetes using an automated insulin delivery (AID) system along with CGM, the use of AID and CGM should be continued during hospitalization if clinically appropriate, with confirmatory POC blood glucose measurements for insulin dosing decisions and hypoglycemia assessment, if resources and training are available, and according to an institutional protocol. C

Continuation of personal CGM device use, particularly for people with type 1 or type 2 diabetes treated with intensive therapy at increased risk for hypoglycemia during hospitalization, is recommended. Confirmatory POC capillary glucose testing, using hospital-calibrated glucose meters, is recommended for insulin dosing and hypoglycemia assessment (e.g., hybrid testing protocols) (51). People with diabetes should be counseled about meaningful use of trend arrows and alarms and about notifying nursing staff for confirmation of these events with POC capillary glucose testing. Similarly, continuation of AID systems should be supported during hospitalization, when clinically appropriate, and with proper staff training and supervision (41,45). Observational studies have demonstrated improvements in patient satisfaction and improved detection of glycemic excursions (40,47). If the reason for admission is suspected to be related to device malfunction or lack of adequate education/training or use, consultation with the endocrinology/diabetes care team or diabetes care and education specialists, if available, is recommended. Hospitals are encouraged to develop institutional policies and have trained personnel with knowledge of diabetes technology. Recent review articles provide details on accuracy, interferences, precautions, and contraindications of diabetes technology devices in the hospital setting (50,51).

An individualized approach for glycemic management is encouraged throughout the hospital stay and should take into consideration several predictive factors for achieving glycemic goals, such as prior home use and dose of insulin or noninsulin therapy, expected level of insulin resistance, prior A1C, current glucose levels, oral intake, and duration of diabetes.

16.8 Basal insulin or a basal plus bolus correction insulin plan is the preferred treatment for noncritically ill hospitalized individuals with poor oral intake or those who are taking nothing by mouth. A

16.9 An insulin plan with basal, prandial, and correction components is the preferred treatment for most noncritically ill hospitalized individuals with adequate nutritional intake. A

A randomized controlled trial has shown that basal plus bolus treatment improved glycemic outcomes and reduced hospital complications compared with a correction or supplemental insulin without basal insulin (formerly known as sliding scale) for people with type 2 diabetes admitted for general surgery (63). Prolonged use of correction or supplemental insulin without basal insulin as the sole treatment of hyperglycemia is strongly discouraged in the inpatient setting, with the exception of people with type 2 diabetes in noncritical care with mild hyperglycemia (2,64,65).

A prospective randomized inpatient study of 70/30 intermediate-acting (NPH)/regular insulin mixture versus basal-bolus therapy showed comparable glycemic outcomes but significantly increased hypoglycemia in the group receiving insulin mixture (66). Therefore, insulin mixtures such as 75/25, 70/30, or 50/50 insulins are not routinely recommended for in-hospital use.

For people with type 1 diabetes, dosing insulin based solely on premeal glucose levels does not account for basal insulin requirements or caloric intake, increasing the risk of both hypoglycemia and hyperglycemia. Typically, basal insulin dosing is based on body weight and expected sensitivity to insulin, with some evidence that people with renal insufficiency should be treated with lower insulin doses (70,71). An insulin schedule with basal and correction components is necessary for all hospitalized individuals with type 1 diabetes, even when taking nothing by mouth, with the addition of prandial insulin when eating. Policies and best practice alerts in the EHR should be put in place to ensure that basal insulin (given subcutaneously, via insulin pump or by insulin infusion) is not held for people with type 1 diabetes, especially during care transitions, and that ongoing prescriber and nursing education is provided (60).

When discontinuing intravenous insulin, a transition protocol is recommended, as it is associated with less morbidity and lower costs of care. Subcutaneous basal insulin should be given 2 h before intravenous infusion is discontinued, with the aim of minimizing rebound hyperglycemia (2,72,73).

16.12 A hypoglycemia management protocol should be adopted and implemented by each hospital or hospital system. A plan for preventing and treating hypoglycemia should be established for each individual. Episodes of hypoglycemia in the hospital should be documented in the electronic health record and tracked for quality assessment and quality improvement. E

People with or without diabetes may experience hypoglycemia in the hospital setting. While hypoglycemia is associated with increased mortality (95,96), in many cases, it is a marker of an underlying disease rather than the cause of fatality. However, hypoglycemia is a severe consequence of dysregulated metabolism and/or diabetes treatment, and it is imperative that it be minimized during hospitalization. Many episodes of inpatient hypoglycemia are preventable. A hypoglycemia prevention and management protocol should be adopted and implemented by each hospital or hospital system. A standardized hospital-wide, nurse-initiated hypoglycemia treatment protocol should be in place to immediately address blood glucose levels

In addition to errors with insulin treatment, iatrogenic hypoglycemia may be induced by a sudden reduction of corticosteroid dose, reduced oral intake, emesis, inappropriate timing of short- or rapid-acting insulin doses in relation to meals, reduced infusion rate of intravenous dextrose, unexpected interruption of enteral or parenteral feedings, delayed or missed blood glucose checks, and altered ability of the individual to report symptoms (107).

In people with diabetes, it is well established that an episode of severe hypoglycemia increases the risk for a subsequent event, partly because of impaired counterregulation (108,109). In a study of hospitalized individuals, 84% of people who had an episode of severe hypoglycemia (defined as

Recently, several groups have developed algorithms to predict episodes of hypoglycemia in the inpatient setting (112,113). Models such as these are potentially important and, once validated for general use, could provide a valuable tool to reduce rates of hypoglycemia in the hospital. In one retrospective cohort study, a fasting blood glucose of

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