Definitions for the quality of the evidence (+OOO, ++OO, +++O, and ++++); the strength of the recommendation (1 or 2); and the difference between a "recommendation" and a "suggestion" are provided at the end of the "Major Recommendations" field.
Diagnosis and Recognition of Hyperglycemia and Diabetes in the Hospital Setting
The Task Force recommends that clinicians assess all patients admitted to the hospital for a history of diabetes. When present, this diagnosis should be clearly identified in the medical record. (1 | +OOO)
The Task force suggests that all patients, independent of a prior diagnosis of diabetes, have laboratory blood glucose (BG) testing on admission. (2 | +OOO)
The Task Force recommends that patients without a history of diabetes with BG greater than 7.8 mmol/liter (140 mg/dl) be monitored with bedside point of care (POC) testing for at least 24 to 48 h. Those with BG greater than 7.8 mmol/liter require ongoing POC testing with appropriate therapeutic intervention. (1 | +OOO)
The Task Force recommends that in previously normoglycemic patients receiving therapies associated with hyperglycemia, such as corticosteroids or octreotide, enteral nutrition (EN) and parenteral nutrition (PN) be monitored with bedside POC testing for at least 24 to 48 h after initiation of these therapies. Those with BG measures greater than 7.8 mmol/liter (140 mg/dl) require ongoing POC testing with appropriate therapeutic intervention. (1 | +OOO)
The Task Force recommends that all inpatients with known diabetes or with hyperglycemia (>7.8 mmol/liter) be assessed with a hemoglobin A1C (HbA1C) level if this has not been performed in the preceding 2–3 months. (1 | +OOO)
Monitoring Glycemia in the Non-Critical Care Setting
The Task Force recommends bedside capillary POC testing as the preferred method for guiding ongoing glycemic management of individual patients. (1 | ++OO)
The Task Force recommends the use of BG monitoring devices that have demonstrated accuracy of use in acutely ill patients. (1 | +OOO)
The Task Force recommends that timing of glucose measures match the patient's nutritional intake and medication regimen. (1 | +OOO)
The Task Force suggests the following schedules for POC testing: before meals and at bedtime in patients who are eating, or every 4–6 h in patients who are NPO [receiving nothing by mouth (nil per os)] or receiving continuous enteral feeding. (2 | +OOO)
Glycemic Targets in the Non-Critical Care Setting
The Task Force recommends a premeal glucose target of less than 7.8 mmol/liter (140 mg/dl) and a random BG of less than 180 mg/dl (10.0 mmol/liter) for the majority of hospitalized patients with non-critical illness. (1 | ++OO)
The Task Force suggests that glycemic targets be modified according to clinical status. For patients who are able to achieve and maintain glycemic control without hypoglycemia, a lower target range may be reasonable. For patients with terminal illness and/or with limited life expectancy or at high risk for hypoglycemia, a higher target range (BG <11.1 mmol/liter or 200 mg/dl) may be reasonable. (2 | +OOO)
For avoidance of hypoglycemia, the Task Force suggests that antidiabetic therapy be reassessed when BG values fall below 5.6 mmol/liter (100 mg/dl). Modification of glucose-lowering treatment is usually necessary when BG values are below 3.9 mmol/liter (70 mg/dl). (2 | +OOO)
Management of Hyperglycemia in the Non-Critical Care Setting
Medical Nutrition Therapy (MNT)
The Task Force recommends that MNT be included as a component of the glycemic management program for all hospitalized patients with diabetes and hyperglycemia. (1 | +OOO)
The Task Force suggests that providing meals with a consistent amount of carbohydrate at each meal can be useful in coordinating doses of rapid-acting insulin to carbohydrate ingestion. (2 | +OOO)
Transition from Home to Hospital
The Task Force recommends insulin therapy as the preferred method for achieving glycemic control in hospitalized patients with hyperglycemia. (1 | ++OOO)
The Task Force suggests the discontinuation of oral hypoglycemic agents and initiation of insulin therapy for the majority of patients with type 2 diabetes at the time of hospital admission for an acute illness. (2 | +OOO)
The Task Force suggests that patients treated with insulin before admission have their insulin dose modified according to clinical status as a way of reducing the risk for hypoglycemia and hyperglycemia. (2 | +OOO)
Pharmacological Therapy
The Task Force recommends that all patients with diabetes treated with insulin at home be treated with a scheduled subcutaneous (sc) insulin regimen in the hospital. (1 | ++++)
The Task Force suggests that prolonged use of sliding scale insulin (SSI) therapy be avoided as the sole method for glycemic control in hyperglycemic patients with history of diabetes during hospitalization. (2 | +OOO)
The Task Force recommends that scheduled sc insulin therapy consist of basal or intermediate-acting insulin given once or twice a day in combination with rapid or short-acting insulin administered before meals in patients who are eating. (1 | +++O)
The Task Force suggests that correction insulin be included as a component of a scheduled insulin regimen for treatment of BG values above the desired target. (2 | +OOO)
Transition from Hospital to Home
The Task Force suggests reinstitution of preadmission insulin regimen or oral and non-insulin injectable antidiabetic drugs at discharge for patients with acceptable preadmission glycemic control and without a contraindication to their continued use. (2 | +OOO)
The Task Force suggests that initiation of insulin administration be instituted at least one day before discharge to allow assessment of the efficacy and safety of this transition. (2 | +OOO)
The Task Force recommends that patients and their family or caregivers receive both written and oral instructions regarding their glycemic management regimen at the time of hospital discharge. These instructions need to be clearly written in a manner that is understandable to the person who will administer these medications. (1 | ++OO)
Special Situations
Transition From Intravenous (IV) Continuous Insulin Infusion (CII) to SC Insulin Therapy
The Task Force recommends that all patients with type 1 and type 2 diabetes be transitioned to scheduled sc insulin therapy at least 1–2 h before discontinuation of CII. (1 | ++++)
The Task Force recommends that sc insulin be administered before discontinuation of CII for patients without a history of diabetes who have hyperglycemia requiring more than 2 U/h. (1 | ++++)
The Task Force recommends POC testing with daily adjustment of the insulin regimen after discontinuation of CII. (1 | +++O)
Patients Receiving EN or PN
The Task Force recommends that POC testing be initiated for patients with or without a history of diabetes receiving EN and PN. (1 | ++++)
The Task Force suggests that POC testing can be discontinued in patients without a prior history of diabetes if BG values are less than 7.8 mmol/liter (140 mg/dl) without insulin therapy for 24–48 h after achievement of desired caloric intake. (2 | +OOO)
The Task Force suggests that scheduled insulin therapy be initiated in patients with and without known diabetes who have hyperglycemia, defined as BG greater than 7.8 mmol/liter (140 mg/dl), and who demonstrate a persistent requirement (i.e. >12 to 24 h) for correction insulin. (2 | +OOO)
Perioperative BG Control
The Task Force recommends that all patients with type 1 diabetes who undergo minor or major surgical procedures receive either CII or sc basal insulin with bolus insulin as required to prevent hyperglycemia during the perioperative period. (1 | ++++)
The Task Force recommends discontinuation of oral and noninsulin injectable antidiabetic agents before surgery with initiation of insulin therapy in those who develop hyperglycemia during the perioperative period for patients with diabetes. (1 | +OOO)
When instituting sc insulin therapy in the postsurgical setting, the Task Force recommends that basal (for patients who are NPO) or basal bolus (for patients who are eating) insulin therapy be instituted as the preferred approach. (1 | +++O)
Glucocorticoid-Induced Diabetes
The Task Force recommends that bedside POC testing be initiated for patients with or without a history of diabetes receiving glucocorticoid therapy. (1 | +++O)
The Task Force suggests that POC testing can be discontinued in nondiabetic patients if all BG results are below 7.8 mmol/liter (140 mg/dl) without insulin therapy for a period of at least 24–48 h. (2 | +OOO)
The Task Force recommends that insulin therapy be initiated for patients with persistent hyperglycemia while receiving glucocorticoid therapy. (1 | ++OO)
The Task Force suggests CII as an alternative to sc insulin therapy for patients with severe and persistent elevations in BG despite use of scheduled basal bolus sc insulin. (2 | +OOO)
Recognition and Management of Hypoglycemia in the Hospital Setting
The Task Force recommends that glucose management protocols with specific directions for hypoglycemia avoidance and hypoglycemia management be implemented in the hospital. (1 | ++OO)
The Task Force recommends implementation of a standardized hospital-wide, nurse-initiated hypoglycemia treatment protocol to prompt immediate therapy of any recognized hypoglycemia, defined as a BG below 3.9 mmol/liter (70 mg/dl). (1 | ++OO)
The Task Force recommends implementation of a system for tracking frequency of hypoglycemic events with root cause analysis of events associated with potential for patient harm. (1 | ++OO)
Implementation of a Glycemic Control Program in the Hospital
The Task Force recommends that hospitals provide administrative support for an interdisciplinary steering committee targeting a systems approach to improve care of inpatients with hyperglycemia and diabetes. (1 | +++O)
The Task Force recommends that each institution establish a uniform method of collecting and evaluating point of care (POC) testing data and insulin use information as a way of monitoring the safety and efficacy of the glycemic control program. (1 | +OOO)
The Task Force recommends that institutions provide accurate devices for glucose measurement at the bedside with ongoing staff competency assessments. (1 | +OOO)
Patient and Professional Education
The Task Force recommends diabetes self-management education targeting short-term goals that focus on survival skills: basic meal planning, medication administration, BG monitoring, and hypoglycemia and hyperglycemia detection, treatment, and prevention. (1 | +OOO)
The Task Force recommends identifying resources in the community to which patients can be referred for continuing diabetes self-management education after discharge. (1 | +OOO)
The Task Force recommends ongoing staff education to update diabetes knowledge, as well as targeted staff education whenever an adverse event related to diabetes management occurs. (1 | +OOO)
Definitions:
Quality of the Evidence
+OOO Denotes very low quality evidence
++OO Denotes low quality evidence
+++O Denotes moderate quality evidence
++++ Denotes high quality evidence
Strength of Recommendations
1 - Indicates a strong recommendation and is associated with the phrase "The Task Force recommends."
2 - Denotes a weak recommendation and is associated with the phrase "The Task Force suggests."
