This is the current release of the guideline.

This guideline updates a previous version: American Diabetes Association (ADA). Standards of medical care in diabetes. VIII. Diabetes care in specific settings. Diabetes Care 2011 Jan;34(Suppl 1):S43-6.

Hospitalized patients with diabetes

For the current revision of this position statement, committee members systematically searched Medline for human studies related to each subsection and published since 1 January 2010.

Not stated

American Diabetes Association's Evidence Grading System for Clinical Practice Recommendations

A

Clear evidence from well-conducted, generalizable randomized controlled trials (RCTs) that are adequately powered, including:

• Evidence from a well-conducted multicenter trial
• Evidence from a meta-analysis that incorporated quality ratings in the analysis

Compelling nonexperimental evidence (i.e., "all or none" rule developed by the Centre for Evidence-Based Medicine at Oxford)

Supportive evidence from well-conducted RCTs that are adequately powered, including:

• Evidence from a well-conducted trial at one or more institutions
• Evidence from a meta-analysis that incorporated quality ratings in the analysis

B

Supportive evidence from well-conducted cohort studies, including:

• Evidence from a well-conducted prospective cohort study or registry
• Evidence from a well-conducted meta-analysis of cohort studies

Supportive evidence from a well-conducted case-control study

C

Supportive evidence from poorly controlled or uncontrolled studies, including:

• Evidence from RCTs with one or more major or three or more minor methodological flaws that could invalidate the results
• Evidence from observational studies with high potential for bias (such as case series with comparison to historical controls)
• Evidence from case series or case reports

Conflicting evidence with the weight of evidence supporting the recommendation

E

Expert consensus or clinical experience

A grading system (see the "Rating Scheme for the Strength of the Evidence" field), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations.

Recommendations (bulleted at the beginning of each subsection and also listed in the "Executive Summary: Standards of Medical Care in Diabetes 2012" [see the "Availability of Companion Documents" field]) were revised based on new evidence or, in some cases, to clarify the prior recommendation or match the strength of the wording to the strength of the evidence. A table linking the changes in recommendations to new evidence can be reviewed at http://professional.diabetes.org/CPR_Search.aspx .

Feedback from the larger clinical community was valuable for the 2012 revision of the standards.

Recommendations have been assigned ratings of A, B, or C, depending on the quality of evidence (see the "Rating Scheme for the Strength of the Evidence" field). Expert opinion (E) is a separate category for recommendations in which there is as yet no evidence from clinical trials, in which clinical trials may be impractical, or in which there is conflicting evidence. Recommendations with an "A" rating are based on large, well-designed clinical trials or well-done meta-analyses. Generally, these recommendations have the best chance of improving outcomes when applied to the population to which they are appropriate. Recommendations with lower levels of evidence may be equally important but are not as well supported.

A formal cost analysis was not performed and published cost analyses were not reviewed.

The standards of care were reviewed and approved by the Executive Committee of the American Diabetes Association's (ADA's) Board of Directors, which includes health care professionals, scientists, and lay people.

The evidence grading system for clinical practice recommendations (A–C, E) is defined at the end of the "Major Recommendations" field.

Diabetes Care in the Hospital

• All patients with diabetes admitted to the hospital should have their diabetes clearly identified in the medical record. (E)
• All patients with diabetes should have an order for blood glucose monitoring, with results available to all members of the health care team. (E)
• Goals for blood glucose levels:
  • Critically ill patients: Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold of no greater than 180 mg/dL (10 mmol/L). Once insulin therapy is started, a glucose range of 140 to 180 mg/dL (7.8 to 10 mmol/L) is recommended for the majority of critically ill patients. (A)
  • More stringent goals, such as 110 to 140 mg/dL (6.1 to 7.8 mmol/L) may be appropriate for selected patients, as long as this can be achieved without significant hypoglycemia. (C)
  • Critically ill patients require an intravenous insulin protocol that has demonstrated efficacy and safety in achieving the desired glucose range without increasing risk for severe hypoglycemia. (E)
  • Non–critically ill patients: There is no clear evidence for specific blood glucose goals. If treated with insulin, the premeal blood glucose targets generally <140 mg/dL (7.8 mmol/L) with random blood glucose <180 mg/dL (10.0 mmol/L) are reasonable, provided these targets can be safely achieved. More stringent targets may be appropriate in stable patients with previous tight glycemic control. Less stringent targets may be appropriate in those with severe comorbidities. (E)
• Scheduled subcutaneous insulin with basal, nutritional, and correction components is the preferred method for achieving and maintaining glucose control in non–critically ill patients.
• Glucose monitoring should be initiated in any patient not known to be diabetic who receives therapy associated with high risk for hyperglycemia, including high-dose glucocorticoid therapy, initiation of enteral or parenteral nutrition, or other medications such as octreotide or immunosuppressive medications. (B) If hyperglycemia is documented and persistent, consider treating such patients to the same glycemic goals as patients with known diabetes. (E)
• 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 patient. Episodes of hypoglycemia in the hospital should be documented in the medial record and tracked. (E)
• Consider obtaining glycosylated hemoglobin (A1C) on patients with diabetes admitted to the hospital if the result of testing in the previous 2 to 3 months is not available. (E)
• Patients with hyperglycemia in the hospital who do not have a prior diagnosis of diabetes should have appropriate plans for follow-up testing and care documented at discharge. (E)

Discharge Planning

It is important to remember that diabetes discharge planning is not a separate entity, but part of an overall discharge plan. As such, discharge planning begins at admission to the hospital and is updated as projected patient needs change.

The optimal program will need to consider the type and severity of diabetes, the effects of the patient's illness on blood glucose levels, and the capacities and desires of the patient. Smooth transition to outpatient care should be ensured. The Agency for Healthcare Research and Quality (AHRQ) recommends that at a minimum, discharge plans include:

• Medication reconciliation: The patient's medications must be cross-checked to ensure that no chronic medications were stopped and to ensure the safety of new prescriptions.
• Whenever possible, prescriptions for new or changed medication should be filled and reviewed with the patient and family at or before discharge.
• Structured discharge communication: Information on medication changes, pending tests and studies, and follow-up needs must be accurately and promptly communicated to outpatient physicians.
• Discharge summaries should be transmitted to the primary physician as soon as possible after discharge.
• Appointment-keeping behavior is enhanced when the inpatient team schedules outpatient medical follow up prior to discharge. Ideally the inpatient care providers or case managers/discharge planners will schedule follow-up visit(s) with the appropriate professionals, including the primary care provider, endocrinologist, and diabetes educator.

It is recommended that the following areas of knowledge be reviewed and addressed prior to hospital discharge:

• Identification of health care provider who will provide diabetes care after discharge
• Level of understanding related to the diagnosis of diabetes, self-monitoring of blood glucose (SMBG), and explanation of home blood glucose goals
• Definition, recognition, treatment, and prevention of hyperglycemia and hypoglycemia
• Information on consistent eating patterns
• When and how to take blood glucose–lowering medications including insulin administration (if going home on insulin)
• Sick-day management
• Proper use and disposal of needles and syringes

It is important that patients be provided with appropriate durable medical equipment, medication, supplies, and prescriptions at the time of discharge in order to avoid a potentially dangerous hiatus in care. These supplies/prescriptions should include:

• Insulin (vials or pens) (if needed)
• Syringes or pen needles (if needed)
• Oral medications (if needed)
• Blood glucose meter and strips
• Lancets and lancing device
• Urine ketone strips (type 1)
• Glucagon emergency kit (insulin-treated)
• Medical alert application/charm

Diabetes and Employment

Employment decisions should never be based on generalizations or stereotypes regarding the effects of diabetes. When questions arise about the medical fitness of a person with diabetes for a particular job, a health care professional with expertise in treating diabetes should perform an individualized assessment. See the National Guideline Clearinghouse (NGC) summary of the American Diabetes Association (ADA) position statement Diabetes and employment.

Diabetes and Driving

The ADA position statement on diabetes and driving recommends against blanket restrictions based on the diagnosis of diabetes and urges individual assessment by a health care professional knowledgeable in diabetes if restrictions on licensure are being considered. Patients should be evaluated for decreased awareness of hypoglycemia, hypoglycemia episodes while driving, or severe hypoglycemia. Patients with retinopathy or peripheral neuropathy require assessment to determine if those complications interfere with operation of a motor vehicle. Health care professionals should be cognizant of the potential risk of driving with diabetes and counsel their patients about detecting and avoiding hypoglycemia while driving.

See the NGC summary of the ADA position statement Diabetes and driving.

Diabetes Management in Correctional Institutions

Correctional institutions should have written policies and procedures for the management of diabetes and for training of medical and correctional staff in diabetes care practices. See the NGC summary of the ADA position statement Diabetes management in correctional institutions.

Definitions:

American Diabetes Association's Evidence Grading System for Clinical Practice Recommendations

A

Clear evidence from well-conducted, generalizable randomized controlled trials (RCTs) that are adequately powered, including:

• Evidence from a well-conducted multicenter trial
• Evidence from a meta-analysis that incorporated quality ratings in the analysis

Compelling nonexperimental evidence (i.e., "all or none" rule developed by the Centre for Evidence-Based Medicine at Oxford)

Supportive evidence from well-conducted RCTs that are adequately powered, including:

• Evidence from a well-conducted trial at one or more institutions
• Evidence from a meta-analysis that incorporated quality ratings in the analysis

B

Supportive evidence from well-conducted cohort studies, including:

• Evidence from a well-conducted prospective cohort study or registry
• Evidence from a well-conducted meta-analysis of cohort studies

Supportive evidence from a well-conducted case-control study

C

Supportive evidence from poorly controlled or uncontrolled studies, including:

• Evidence from RCTs with one or more major or three or more minor methodological flaws that could invalidate the results
• Evidence from observational studies with high potential for bias (such as case series with comparison to historical controls)
• Evidence from case series or case reports

Conflicting evidence with the weight of evidence supporting the recommendation

E

Expert consensus or clinical experience

None provided

The type of supporting evidence is identified and graded for most recommendations (see the "Major Recommendations" field).

Appropriate diabetes care in hospitalized patients

Specific caution is required with metformin, due to the possibility that a contraindication may develop during the hospitalization, such as renal insufficiency, unstable hemodynamic status, or need for an imaging study that requires a radio-contrast dye.

While numerous interventions to improve adherence to the recommended standards have been implemented, a major barrier to optimal care is a delivery system that too often is fragmented, lacks clinical information capabilities, often duplicates services, and is poorly designed for the coordinated delivery of chronic care. The Chronic Care Model (CCM) includes six core elements for the provision of optimal care of patients with chronic disease: 1) delivery system design (moving from a reactive to a proactive care delivery system, where planned visits are coordinated through a team-based approach; 2) self-management support; 3) decision support (basing care on evidence-based, effective care guidelines); 4) clinical information systems (using registries that can provide patient-specific and population-based support to the care team); 5) community resources and policies (identifying or developing resources to support healthy lifestyles); and 6) health systems (to create a quality-oriented culture). Redefinition of the roles of the clinic staff and promoting self-management on the part of the patient are fundamental to the successful implementation of the CCM. Collaborative, multidisciplinary teams are best suited to provide such care for people with chronic conditions like diabetes and to facilitate patients' performance of appropriate self-management.

National Diabetes Education Program (NDEP) maintains an online resource (www.betterdiabetescare.nih.gov ) to help health care professionals design and implement more effective health care delivery systems for those with diabetes.

Three specific objectives are outlined below.

Objective 1: Optimize Provider and Team Behavior

The care team should prioritize timely and appropriate intensification of lifestyle and/or pharmaceutical therapy of patients who have not achieved beneficial levels of blood pressure, lipid, or glucose control. Strategies such as explicit goal setting with patients; identifying and addressing language, numeracy, or cultural barriers to care; integrating evidence-based guidelines and clinical information tools into the process of care; and incorporating care management teams including nurses, pharmacists, and other providers have each been shown to optimize provider and team behavior and thereby catalyze reduction in glycosylated hemoglobin (A1C), blood pressure, and low-density lipoprotein (LDL) cholesterol.

Objective 2: Support Patient Behavior Change

Successful diabetes care requires a systematic approach to supporting patients' behavior change efforts, including (a) healthy lifestyle changes (physical activity, healthy eating, nonuse of tobacco, weight management, effective coping), (b) disease self-management (medication taking and management, self-monitoring of glucose and blood pressure when clinically appropriate); and (c) prevention of diabetes complications (self-monitoring of foot health, active participation in screening for eye, foot, and renal complications, and immunizations). High-quality diabetes self-management education (DSME) has been shown to improve patient self-management, satisfaction, and glucose control, as has delivery of ongoing diabetes self-management support (DSMS) so that gains achieved during DSME are sustained. National DSME standards call for an integrated approach that includes clinical content and skills and behavioral strategies (goal-setting, problem solving) and addresses emotional concerns in each needed curriculum content area.

Objective 3: Change the System of Care

The most successful practices have an institutional priority for providing high quality of care. Changes that have been shown to increase quality of diabetes care include basing care on evidence-based guidelines, expanding the role of teams and staff, redesigning the processes of care, implementing electronic health record tools, activating and educating patients, and identifying and/or developing and engaging community resources and public policy that support healthy lifestyles. Recent initiatives such as the Patient Centered Medical Home show promise to improve outcomes through coordinated primary care and offer new opportunities for team-based chronic disease care. Alterations in reimbursement that reward the provision of appropriate and high quality care rather than visit-based billing, and that can accommodate the need to personalize care goals, may provide additional incentives to improve diabetes care.

It is clear that optimal diabetes management requires an organized, systematic approach and involvement of a coordinated team of dedicated health care professionals working in an environment where patient-centered high-quality care is a priority.

Not applicable: The guideline was not adapted from another source.

American Diabetes Association

Professional Practice Committee

Committee Members: Roger Anderson, MS, RPH, CDE; Susan Braithwaite, MD; Martha Funnell, MSN, RN, CDE; Robert Gabbay, MD; Richard Grant, MD, MPH; Jane Kadohiro, DrPH, APRN, CDE; James Lenard, MD; Daniel Lorber, MD; Michelle Magee, MD; Sunder Mudaliar, MD; Patrick O'Connor, MD, MPH; R. Harsha Rao, MD; Andrew Rhinehart, MD, CDE; Stuart Weinzimer, MD; Carol Wysham, MD (Chair); Gretchen Youssef, MS, RD, CDE; Judy Fradkin, MD (Ex officio); Stephanie Dunbar, RD, MPH (Staff); Sue Kirkman, MD (Staff)

Members of the Professional Practice Committee disclose all potential financial conflicts of interest with industry.

Members of the committee, their employer, and their disclosed conflicts of interest are listed in the "Professional Practice Committee Members" table and are available from the American Diabetes Association (ADA) Web site (see the "Availability of Companion Documents" field).

This is the current release of the guideline.

This guideline updates a previous version: American Diabetes Association (ADA). Standards of medical care in diabetes. VIII. Diabetes care in specific settings. Diabetes Care 2011 Jan;34(Suppl 1):S43-6.

Electronic copies: Available from the Diabetes Care Journal Web site .

Print copies: Available from the American Diabetes Association, 1701 North Beauregard Street, Alexandria, VA 22311.

The following are available:

• Introduction. Diabetes Care 2012 Jan;35(Suppl 1):S1-S2.
• Summary of revisions for the 2012 clinical practice recommendations. Diabetes Care 2012 Jan;35(Suppl 1):S3.
• Executive summary: standards of medical care in diabetes. Diabetes Care 2012 Jan;35(Suppl 1):S4-S10.
• Diagnosis and classification of diabetes mellitus. Diabetes Care 2012 Jan;35(Suppl 1):S64-S71.
• Third-party reimbursement for diabetes care, self-management education, and supplies. Diabetes Care 2012 Jan;35(Suppl 1):S99-100.
• Professional Practice Committee 2012 (includes conflict of interest disclosure). Diabetes Care 2012 Jan;35(Suppl 1):S109-S110.

Electronic copies: Available from the Diabetes Care Journal Web site .

Print copies: Available from the American Diabetes Association, 1701 North Beauregard Street, Alexandria, VA 22311.

The following is also available:

• 2012 Standards of medical care in diabetes. Clinical practice recommendations. Slide set. American Diabetes Association; 2012 Jan. 150 p. Electronic copies: Available from the American Diabetes Association (ADA) Web site .

None available

This summary was completed by ECRI on April 2, 2001. The information was verified by the guideline developer on August 24, 2001. This summary was updated by ECRI on April 21, 2003, May 26, 2004, July 1, 2005, and March 17, 2006 and April 26, 2007. This summary was updated by ECRI Institute on April 1, 2008. The updated information was verified by the guideline developer on May 15, 2008. This summary was updated by ECRI Institute on May 20, 2010. The information was verified by the guideline developer on May 25, 2010. This summary was updated by ECRI Institute on February 26, 2011. This NGC summary was updated by ECRI Institute on May 10, 2012.

This NGC summary is based on the original guideline, which is copyrighted by the American Diabetes Association (ADA).

For information on guideline reproduction, please contact Alison Favors, Manager, Rights and Permissions by e-mail at permissions@diabetes.org.

For information about the use of the guidelines, please contact the Clinical Affairs Department at (703) 549-1500 ext. 1692.