Identification, Initial Assessment, and Management Plan
Goal Statement: To identify all patients with diabetes, document attendant comorbidities/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 American Diabetes Association (ADA) screening guidelines for all patients.
|
Admitting or emergency department nurse |
On admission, pre-admission, or presentation to the emergency department |
| The remainder of these guidelines is 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/registered nurse (RN)/licensed practical nurse (LPN)/certified diabetes educator (CDE)/registered dietician (RD) |
On admission/pre-admission |
- Documentation of symptoms of diabetes-related comorbidities 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 |
- Electrocardiogram (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 |
- Glycated hemoglobin (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.
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 that 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 upper glycemic targets as indicated in the original guideline document without assessment and/or intervention.*
| Upper Limits For Glycemic Targets for Non-Pregnant Adults* |
Intensive Care Unit |
Non-Critical Care Units |
| 110mg/dL |
(Preprandial) 110mg/dL |
(Maximum Glucose) 180 mg/dL |
*Evidence regarding the risks of hyperglycemia in the hospitalized patient and benefits of aggressive management has been obtained in studies of adult patients with a variety of acute and chronic medical conditions. It is not known whether these same risks and benefits apply to children. Careful judgment must be used in the application of the upper limits for glycemic targets in the pediatric population.
| |
Intervention |
Health Care Professional1 |
Event/Frequency |
| Monitoring |
- A1c
|
Physician |
On admission, unless documented within previous one month |
- Bedside plasma glucose monitoring#, recorded on an appropriate flow sheet##
|
Physician/Nurse/Lab |
- A minimum of 4 times per day:
-Before meals and bedtime for patients orally fed;
-Every 4 to 6 hours during nothing by mouth (NPO) status
- Hourly monitoring for patients treated with continuous intravenous insulin infusion therapy until values are stable, then consider reducing frequency to every 2 to 3 hours
|
- Blood glucose review
|
Physician |
Daily### |
- Alert values reported to physician
|
Nurse/Lab |
PG <60 mg/dL, or per hypoglycemia treatment order, PG >300 mg/dL, or by physician specification |
| Maintenance |
- Reassess/adjust regimen*
|
Physician |
- On non-critical care units, adjustments in the diabetes regimen are often needed to maintain PG values below the upper limits for glycemic targets. (The use of "sliding scale" insulin coverage as the sole treatment of hyperglycemia has been shown to be ineffective.)
- During intensive care situations, continuous intravenous (IV) insulin infusion is often required to maintain PG values below the upper limits for glycemic targets.
|
- 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 despite intervention
- Major surgery
- Diabetic ketoacidosis (DKA)
- Hyperosmolar hyperglycemic state (HHS)
- Severe or recurrent hypoglycemia or neuroglycopenic symptoms
- Acute macrovascular events
- Serious infections or non-healing wounds
Should be obtained:
- Pump therapy
- Pregnancy
|
| Order Sets*** |
- Hypoglycemia Treatment Order
|
Physician/Nurse |
PG < 70 mg/dL |
- Continuous IV Insulin Infusion
|
Physician/Nurse |
Examples may include:
- DKA or HHS
- Critically ill
- Type 1 and type 2 diabetes and NPO for >12 to 24 hours
- Major or minor surgery and PG >150 mg/dL
- Acute myocardial infarction and PG >180 mg/dL
- Women with hyperglycemia during labor and delivery
|
- Perioperative Order
|
Physician/Nurse |
Pre-admission or as soon as possible prior to surgery |
- External Insulin Pump Order
|
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 maximum preprandial PG > 110 mg/dL and maximum postprandial PG >180mg/dl are reoccurring. Intensive monitoring (>4 x daily) may be required under special circumstances as post myocardial infarction (MI), total parenteral nutrition (TPN), steroid therapy, etc.
*Regimen includes nutrition, activity, medication, and other therapeutic modalities. If insulin sliding scales are utilized, it is recommended that a hospital protocol be developed. A subcutaneous sliding scale insulin regimen should be used in combination with a scheduled insulin and/or oral agent regimen.
**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 or a consultant.
***Hospital medical staffs are encouraged to develop and implement appropriate routine order sets for people with diabetes.
Medical Nutrition Therapy
Goal Statement: To optimize glycemic 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.
| |
Intervention |
Health Care Professional1 |
Event/Frequency |
| Establishment, Monitoring and Maintenance |
- 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
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
| |
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 insulin administration, 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 |
- Follow-up diabetes management appointment recommended or arranged
|
Physician, RN, CDE or RD; with patient/caregiver |
Prior to discharge |
1 In 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 Education Curriculum" in the original guideline document
**** See Exhibit D - "Standards of Care" in the original guideline document
Optimal Glycemic 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:
Pre-labor: Fasting plasma glucose 6590 mg/dL; One hour postprandial plasma glucose <120mg/dL; A1c <6.0% during all trimesters
Labor and Delivery: Plasma glucose <100 mg/dL
| |
Intervention |
Health Care Professional1,2 |
Event/Frequency |
| Monitoring |
- A1c with normal range in pregnancy established
|
Physician |
On admission |
- Finger stick plasma glucose
|
Physician/Nurse/Lab |
Before and one hour after each meal, at bedtime, and at 3:00 am |
- Plasma glucose review
|
Physician |
Daily# |
- Alert values reported to physician
|
Nurse/Lab |
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 |
| Order Sets |
- Gestational diabetes mellitus (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 |
1 In consultation with patient/caregiver
2 Consultation 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 to 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%)
***Order should include specific instructions for management of hypoglycemia.
