Jane Jeffrie Seley, DNP, MPH, MSN, GNP, BC-ADM, CDE, CDTC, FAAN FAADE1
1Seley is Diabetes Nurse Practitioner at NewYork-Presbyterian/ Weill Cornell Medicine, New York, NY
Although mounting evidence supports short-term glycemic control in acutely ill patients in increasingly acute care settings, many hospitals continue to struggle with reaching recommended glycemic targets. Clinical inertia, or the failure to advance therapy when goals are not met, is common in hospitals. Late adopters of intensification of glucose control remain uncertain that evidence is sufficient that short-term hyperglycemia leads to poor outcomes and some health-care providers are unsure of the necessary steps to achieve targets.1–3 Fear of hypoglycemia is often a major driver of suboptimal diabetes management during hospitalization because diabetes often is not the primary diagnosis and patients may be under the care of clinicians who are not well versed in insulin therapy.1 To resolve this conundrum, organizations such as the American Diabetes Association (the Association), the American Association of Clinical Endocrinologists (AACE), the American Association of Diabetes Educators (AADE), the Endocrine Society, and the Joint Commission have made inpatient diabetes management and education a priority and have offered recommendations to guide health-care providers to safely achieve glycemic control.4–7
The diabetes epidemic is evident in the inpatient setting with a reported prevalence of up to 38% in community hospitals in the U.S.6 A 2010 Healthcare Cost and Utilization Project (HCUP) Statistical Brief estimated that although people with diabetes made up ~8% of the general population, they represent almost three times that number in the inpatient setting, along with longer length of stays and higher costs.8 It is during acute hospitalization that many patients learn that they have diabetes for the first time. Of the 38% of inpatients with hyperglycemia, 26% have preexisting diabetes, and the remaining 12% have either newly diagnosed diabetes or stress hyperglycemia secondary to acute illness or medications.9 This finding presents an opportunity to identify untreated diabetes before discharge and to send the patient home on an appropriate self-care regimen.
Controlling blood glucose (BG) during hospitalization in patients with known diabetes is particularly challenging because meals often are interrupted and patients often experience changes in appetite, available food choices, medication taking, physical activity, and sleep-and-wake cycles. Patients who routinely self-manage their diabetes at home suddenly are placed in a position in which their care is taken over by others, who may lack understanding regarding the need for coordination of glucose monitoring, meals, and medication. The frequent fluctuations of BG levels during an acute illness may be disturbing to patients who have maintained more reasonable glycemic control at home when they were not acutely ill. Health-care professionals should be sensitive to these issues when caring for patients with preexisting diabetes and should discuss inpatient versus outpatient targets and treatment strategies with them.
The challenge of overseeing this comprehensive care and facilitating a safe discharge plan is often the role of the diabetes educator or the bedside nurse who spends the most time with the patient and family.10 In the inpatient setting, bedside nurses should be the key providers of diabetes self-management education as well as the patient advocate regarding the feasibility of the proposed home diabetes regimen.
THE CASE FOR GLYCEMIC CONTROL IN THE HOSPITAL SETTING
Reducing episodes of hypo- or hyperglycemia during hospitalization can improve both morbidity and mortality by supporting healing, reducing length of stay, lowering risk of infection, and promoting patient well-being.5,6Improved glycemic control has proven to be beneficial in studies in diverse populations, such as postacute myocardial infarction (MI), cardiac surgery, and critically ill patients in a surgical intensive care unit (SICU). The appropriate glucose targets, however, currently are under scrutiny.
In the Diabetes Mellitus, Insulin Glucose Infusion in Acute Myocardial Infarction (DIGAMI) study reported in 1997, patients had a 29% reduction in mortality 1 year after receiving intravenous insulin in the first 24 h post MI and multiple injections of subcutaneous insulin for the next 3 months.11 In a study published in 2003, Furnary et al.12 achieved a 66% reduction in mortality with mean BG levels of <150 mg/dL using intravenous insulin compared with prior use of subcutaneous injections in cardiac surgery patients. In a study published in the New England Journal of Medicine in 2001, Van den Berghe et al.13 demonstrated reduced mortality by 34% and sepsis by 46% in a SICU by lowering BG levels to <110 mg/dL. This study, conducted in Belgium, raised the importance of glycemic control in the intensive care unit (ICU) to international attention. In a retrospective chart review of general medicine and surgery in patients in 2002, Umpierrez et al.9 found that patients with new hyperglycemia and known diabetes had an 18-fold and 2.7-fold increased mortality risk, respectively, if the BG levels >126 mg/dL fasting or 200 mg/dL random at least twice during hospitalization. These findings were important because they showed that tighter targets were needed in the noncritical care setting as well.
The evidence in the early 2000s shifted the pendulum from a lack of concern about short-term hyperglycemia to a focus on stricter glycemic targets in acute care. By the end of that decade, new evidence raised concerns that the stricter targets may be too tight and should be reevaluated.
When choosing critical care and noncritical care targets, each institution must consider the current culture and practice. Barriers such as fear of hypoglycemia and lack of understanding of basal-bolus insulin therapy are real concerns that must be addressed through interdisciplinary discussions, consensus-building, and subsequent staff education.14 Conservative targets may be established initially and then modified as staff become more competent and confident in following comprehensive order sets and protocols.
BLOOD GLUCOSE TARGETS IN THE HOSPITAL SETTING
Critically Ill Patients
More recent studies in ICUs have not supported the recommendations of stricter goals of 80–120 mg/dL in most settings.13,15 On the basis of a meta-analysis of more recent studies, including the often-debated Normoglycemia in Intensive Care Evaluation-Survival Using Glucose Algorithm Regulation (NICE-SUGAR) trial, BG targets in critical care were raised to 140–180 mg/dL for most patients.15 A stricter target such as 110–140 mg/dL may be reasonable for select patients as long as significant hypoglycemia does not occur. This allows institutions to make their own decisions about targets as long as they can show safety along with efficacy.
With that in mind, a hospital may establish two possible glycemic goals in the ICUs: 100–140 mg/dL or 140–180 mg/dL. Each ICU can decide which goal or goals are appropriate for their patient population. Units such as the SICU may choose to follow the more intensive goal based on Van den Berghe’s findings in the SICU and extensive in-house validation, whereas the medical intensive care unit (MICU) may have both goals available depending on the clinical status of each patient. ICU patients often have rapidly changing insulin requirements that are best addressed with intravenous insulin infusions that have demonstrated efficacy and safety in achieving the desired glucose range in a timely fashion without significantly increasing risk for severe hypoglycemia.16
Hospitals may choose to validate a homegrown protocol, utilize a published protocol, or purchase automated dose calculator software. In a study with 300 ICU patients comparing a nurse-managed paper protocol to a computerized version, results yielded statistically significant improvements in glycemic control and decreased glucose variability with the computerized protocol, as well as less deviation from the protocol and greater nurse satisfaction.17 Although a cost is associated with computerized protocols, the benefits to both the patient and the institution appear to justify the expenditure.
Noncritically Ill Patients
Evidence is limited for specific BG goals in the noncritical care setting. The Association recommends target BGs of 140–180 mg/dL for most patients. The Association suggests stricter targets <140 mg/dL for patients who are well controlled at home and looser targets for patients who are terminally ill or have comorbidities that would limit the safety of tighter glycemic control.18 In contrast, the Endocrine Society guidelines published in 2012 recommend a premeal BG of <140 mg/dL with any random BG of <180 mg/dL for most patients.6 To avoid hypoglycemia, they go on to recommend reducing diabetes medications when the BG is <100 mg/dL, although the Association recommends the treatment regimen should be reviewed and changed as necessary when BG <70 mg/dL.
The preprandial target at New York–Presbyterian Hospital (NYPH) is 100–140 mg/dL, stressing the importance of reducing insulin doses when BGs drop below the target. Following a study at the Weill Cornell campus, which showed that a fasting BG of <100 mg/dL was a strong predictor of hypoglycemia the next day, the NYPH issued a written recommendation to educate the staff to lower the basal insulin dose when fasting BG dropped <100 mg/dL.19
Insulin remains the preferred anti hyperglycemic agent to treat hyperglycemia in acutely ill patients. Because of possible contraindications during acute illness, oral agents, and noninsulin injectable therapies currently are not recommended in the hospital setting. If the patient is clinically stable, eating well, and close to discharge, these medications could be resumed to test the efficacy of the proposed discharge regimen.6,18
Glycemic control protocols or order sets may make it easier for clinicians to place appropriate insulin and related orders to achieve recommended targets. Orders may include a carbohydrate-controlled diet; bedside, point-of-care (POC) blood glucose monitoring (BGM) schedules; initial insulin starting doses for basal, prandial, and correction insulin, and specific instructions for nursing staff that delineate challenging situations, such as when to hold insulin and call the prescriber for orders.20–22 Although many protocols do not include insulin titration algorithms to guide dose adjustments when targets are not met, they are a step in the right direction toward avoiding clinical inertia and improving glycemic control.
Hospital routines, products, policies, and protocols should be reviewed on an ongoing basis to evaluate possible conflicts or to align them with up-to-date diabetes management best practices. The clinical staff must remain knowledgeable about current strategies that improve glycemic control while avoiding acute complications such as hypoglycemia.
THE NURSE’S ROLE IN INPATIENT DIABETES CARE
Nurses have multiple roles to play in the care of the hospitalized patient with diabetes or hyperglycemia. They may be part of a team that develops policies and protocols or be responsible for educating other nursing staff. The bedside nurse who spends the entire shift with the patient is in a perfect position to assess and identify patient needs and address knowledge deficits during hospitalization and in discharge planning post hospitalization. In most hospitals, the nurse is ultimately responsible for the direct care and education of the patient and the coordination of the team that assists in the implementation of care. Bedside nurses play a key role in recognizing the signs and symptoms of hypoglycemia and identifying root causes. Diabetes educators can partner with nursing to design educational interventions that reduce hypoglycemia in the hospital setting. Many hospitals have nurses who function as care coordinators who are assigned to high-risk patients to monitor the inpatient stay and facilitate safe discharge planning and prevent readmission.23,24
System-Wide Approach to Inpatient Management
Many strategies can be implemented to improve diabetes care in the hospital setting, but the most accepted strategy is a system-wide approach with the creation of an interdisciplinary team to seek opportunities and solutions to improve diabetes care across settings.4,5,7,24 The team should include representation from all disciplines and departments that provide routine care to patients with diabetes. The team usually includes but is not limited to an endocrinologist; diabetes educator; nurse leader, such as a clinical nurse specialist or unit manager; nurse educator or bedside nurse; pharmacist; registered dietitian; care manager; POC testing administrator; information technology manager; and a medical resident, physician’s assistant, nurse practitioner, or hospitalist who places insulin orders. Team responsibilities include a review of the current evidence and published protocols and practices, and the creation, adoption, and evaluation of protocols, order sets, and other related clinical standards of care.2 Table 34.1 delineates some of the roles and functions of glycemic control teams.
Table 34.1—Recommended Structure, Protocols, Metrics, and Strategies for Hospital Glycemic Teams
Source: Reproduced from Rodriguez.24
Assessing the Patient
Management of the hospitalized patient with diabetes can be challenging, with shortened inpatient stays and complex medication regimens coupled with comorbidities and diabetes-related chronic complications. Regardless of the reason for admission, it is essential to identify patients with acute hyperglycemia or poorly controlled diabetes at the time of hospital admission, or a patient that may be at increased risk for hyperglycemia because of therapeutic interventions, such as steroid use or enteral feedings. Once a patient is identified as high risk, BGM and possibly insulin therapy (depending on the level of glycemia) should be ordered.4 Key information that should be obtained on the nursing admission assessment includes type and duration of diabetes, recent weight changes, and details about the home self-care regimen, including meal patterns, monitoring, and medications as well as family support.6,18
Nurses should seek opportunities to improve diabetes self-care behaviors, particularly if suboptimal glycemic control is the underlying cause for hospitalization. During illness, the counterregulatory hormones increase, resulting in increased insulin resistance and marked hyperglycemia. Those patients with ineffective or suboptimal home regimens, evidenced by hemoglobin A1c (A1C) values >7% are at increased risk for severe hyperglycemia leading to diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic syndrome (HHS) (see Chapter 9, Acute Complications of Diabetes). Careful monitoring of BG levels and appropriate interventions to meet target goals for glycemic levels are essential to reduce risk and promote optimal outcomes. Diabetes knowledge and performance of self-care, including coping skills, need to be assessed on an ongoing basis from the time of admission.18
Hospital Point-of-Care Glucose Monitoring
A1C testing and POC BGM are recommended for all patients with or at risk for hyperglycemia.2,18 The Association defines hyperglycemia as a BG level >140 mg/dL (7.8 mmol/L). The A1C result can be used to evaluate diabetes control before admission in patients with previously diagnosed diabetes and to determine whether a patient with new persistent hyperglycemia actually has undiagnosed diabetes when the A1C is ≥6.5% (48 mmol/L).2,18,25 The definitions of hypoglycemia with <70 mg/dL (3.9 mmol/L) considered as an alert value and hypoglycemia associated with severe cognitive impairment requiring external assistance for recovery considered as severe, are unchanged from outpatient to inpatient.
Goals for BG Levels in the Hospital Setting
Critically ill patients: BG targets in critical care are 140–180 mg/dL for most patients. A stricter target such as <140 mg/dL may be reasonable for select patients as long as significant hypoglycemia does not occur.18 This allows institutions to make their own decisions about targets as long as they can show safety along with efficacy.
Noncritically ill patients: Evidence is limited for specific BG targets in the noncritical care setting. The Association recommends target BGs of 140–180 mg/dL for most patients. In addition, the Association suggests stricter targets <140 mg/dL for patients who are well controlled at home, and looser targets for patients who are terminally ill or have comorbidities that would limit the safety of tighter glycemic control.
Scheduled preprandial insulin doses should be appropriately timed in relation to BGM and meals and adjusted according to POC glucose patterns. Sliding-scale insulin regimens, or the use of short- or rapid-acting insulin alone, are not recommended because they are not physiologic. Basal insulin or a basal plus bolus correction insulin regimen is the preferred treatment for noncritically ill patients with poor oral intake or those who are taking nothing by mouth (NPO). An insulin regimen with basal, nutritional, and correction components is the preferred treatment for noncritically ill hospitalized patients with good nutritional intake.
Source: From the American Diabetes Association.18
During hospitalization, the timing of POC BGM should be scheduled according to the patient’s nutritional status and medication regimen to achieve optimal glycemic control. Patients who are NPO can have orders for BGM every 4–6 h or more frequently if unstable or on an intravenous insulin infusion, in which case hourly monitoring is common.18
Patients who require enteral feedings or parenteral nutrition usually require BGM every 4–6 h. For patients who are eating regularly, BGM usually is ordered before or as close to the meal as possible and at bedtime. A written nursing policy is recommended to delineate the acceptable times to perform the BG check (no longer than 1 h before the meal, <30 min is preferred) and to administer mealtime insulin in relation to meal tray delivery. Some hospitals educate the nurses to count carbohydrates consumed and dose the mealtime insulin immediately after the meal. This is an advanced skill that requires additional nursing education.
Specific patient situations may warrant closer monitoring such as hourly BGM when initiating and titrating intravenous insulin and whenever the patient is critically ill. According to Clement et al.,4 once a patient’s insulin drip rate has stabilized and the glycemic target has been achieved, the frequency of BGM can be reduced to every 2–3 h. This criteria is especially important on general care floors that support intravenous insulin in cases in which protocols are less aggressive because of staffing ratios that differ from those in the ICU. The accuracy of POC BG meters for use in the ICU setting recently has come into question. In the original U.S. Food and Drug Administration (FDA) clearance, these meters were evaluated based on studies conducted in the outpatient population and not the intended use in critically ill patients.26,27 The accuracy of the BG result is crucial because it will be used to determine the insulin dose and treat hypo- and hyperglycemia. With this in mind, some hospital laboratories have conducted their own validation studies, whereas others have considered manufacturers’ FDA approval status when choosing a new device.
The FDA requirements based on the 2003 International Organization for Standardization (ISO) standard, required that 95% of BGs be within 15 mg/dL when the BG is <75 mg/dL and within 20% when the BG is ≥75 mg/dL compared with the laboratory. In 2016, FDA guidance was updated and now requires 99% of values be within 7 mg/dL when the BG is <70 mg/dL and no more than 10% variability for BGs >70 mg/dL.26
The usefulness and accuracy of continuous glucose monitoring (CGM) in the hospital setting is currently under investigation. Because POC BG meters only measure glucose at that moment in time, CGM might be a better fit for use with intravenous insulin infusions. Because CGM detects trends, it could prove to be an important tool in preventing hypo- and hyperglycemia in insulin-treated patients by detecting rapid glucose excursions earlier and be of use both in the ICUs and on general floors.28 It remains to be seen whether the accuracy and safety of CGM in acutely ill patients mirrors the results with the outpatient population.
Nurses always should use clinical judgment to assess patients and repeat BGM when BG results do not match the clinical presentation. Incidences of hypo- and hyperglycemia may be prevented by increasing the frequency of BGM when changes are made in medications (e.g., steroids, insulin) and to nutritional status known to alter BG (e.g., NPO, enteral feedings, total parenteral nutrition). Accuracy of results may increase when the finger is cleaned before lancing to remove any glucose contamination, such as food. Consistent use of a single source to obtain the blood sample (capillary, venous, or arterial) in each patient will reduce unnecessary variability in results.18 Because nurses rely on BGM to administer insulin to their patients, they should play an influential role in evaluating bedside BGM systems and making recommendations regarding ease of use, accuracy requirements, connectivity to the electronic medical record, and patient comfort. The blood sample size and choice of lancet are key areas to focus on when considering comfort. Whenever possible, patients should participate in obtaining their own blood sample, applying the blood to the test strip, evaluating the result, and determining what action to take, as a learning opportunity. Although the home glucose testing device is not the same as that used in the hospital, these core skills are transferable to self-management at home.
Some patients feel more comfortable bringing their home glucose meters with them to the hospital so that they can check their BG at any time. This provides an opportunity for the nurse to validate the accuracy of the home meter and the patient’s competency in using the device. When comparing the patient meter results to the hospital meter, expect up to a 20% variance in results. Patient use of a personal meter in the hospital should be addressed in a nursing policy. The hospital meter must be used for all treatment decisions and charting because quality control is done on the hospital meter daily, and the glucose results often are transferred into the electronic medical record. Patients can use their own meters if they want to know their glucose levels between hospital checks, but the nurse should confirm an abnormal value with the hospital meter before acting on the result.
Although BG data are essential for patient treatment decisions, they also can contribute to the improvement of diabetes management in the hospital setting. The BG data collected on each hospital unit provides an opportunity for performance improvement by evaluating rates of hypoglycemia and hyperglycemia by patient type, location, and insulin regimen. This form of glucometrics, or standardized measures of glycemia, can guide the development, evaluation, and revision of protocols and order sets.29,30 Progress toward achieving glycemic targets unit by unit can be tracked, and educational interventions can be targeted based on need (see Table 34.2).
Table 34.2—Benchmarking for Selected Glucometrics from 76 Hospitals: Core Non-ICU Adult Units
|
Mean |
Median |
Range |
Top 25th percentile |
|
|
Patient day-weighted mean POC blood glucose (mg/dL) |
162 |
164.4 |
128.4–187.5 |
≤157.0 |
|
Patient-day POC blood glucose means ≥180 mg/dL (%) |
29.5 |
30.5 |
12.0–45.8 |
≤21 |
|
Stays with POC blood glucose mean (day-weighted) ≥180 mg/dL (%) |
27.5 |
28.4 |
6.8–43.3 |
≤24 |
|
Patient-days with any POC blood glucose >299 mg/dL (%) |
10.5 |
10.9 |
2.7–21.5 |
≤6.9 |
|
Patient-days with any POC blood glucose <70 mg/dL (%) |
5.0 |
4.9 |
1.7–13.1 |
≤3.3 |
|
Patient-days with any POC blood glucose <40 mg/dL (%) |
0.6 |
0.5 |
0.1–1.6 |
≤0.3 |
|
Hypoglycemic patients with recurrence (%) |
32.4 |
33.2 |
7.0–52.7 |
≤27.3 |
|
Mean time to resolution of hypoglycemia (minutes) |
127 |
120 |
39–245 |
≤78 |
Source: Reproduced from Maynard.31
Regulatory and licensing agencies mandate that hospitals must have quality improvement (QI) programs for BGM. Correlation studies comparing bedside results with laboratory values are essential elements of the QI program. Some common sources of error that can affect results include incorrect application of blood to the test spot; meter cleaning errors, especially at the docking contact points; damaged test strips; expired control solution; unclean fingers or hands; and environmental changes, such as temperature, humidity, and light.26 Reducing sources of error is an essential component in ensuring that the BG result is accurate and treatment decisions are safe and effective.
Nutrition
Goals of nutrition therapy include providing adequate calories to meet the increased nutritional needs of the acutely ill while balancing metabolic control, including glucose, lipids, and blood pressure. Diabetes control is challenging when adjustments in nutrition orders, such as NPO, clear liquids, and parenteral or enteral feedings, are necessary for the treatment of other conditions. Medication adjustments need to match the altered intake to avoid acute complications, most notably hypoglycemia. Patients should be monitored carefully for BG excursions resulting from changes in their meal plan and appropriate adjustments should be made on a daily basis, if needed.32
As in the outpatient setting, controlled or consistent carbohydrate meal planning is recommended. Although consistent carbohydrate counting presents a loss of flexibility for the patient, offering the same amount of carbohydrates on each meal tray is a simpler plan that provides a way to easily match the prandial insulin dose to a known amount of carbohydrate.18,32 Patients who are accustomed to dosing insulin based on the amount of carbohydrates eaten may be allowed a more flexible meal plan. To provide consistent carbohydrates, a number of system changes may be needed. The hospital menus may need to be examined to calculate the carbohydrate content of foods served. Carbohydrate-friendly menus should clearly identify which foods contain carbohydrate to the nearest half serving or the number of grams and identify how many servings or total grams of carbohydrate the patient is offered for the meal. This allows the patient to order the correct amount of carbohydrate, thus avoiding the disappointment when the tray comes up and items have been deleted arbitrarily because the patient selected more than the meal plan allows. For many patients who have not had previous diabetes education, the hospital setting may be the initial exposure to carbohydrate counting. This type of menu becomes a learning tool for teaching carbohydrate counting and practicing the skill with each meal tray.32
Hospital routines often lead to a mismatch of when the BG is checked, the insulin is given, and the meal is consumed. Streamlining this can vastly improve glycemic control. One strategy employed successfully in a large city hospital restricted the timing of the BG test to no sooner than 1 h before meal tray delivery and expedited the tray delivery so that patients with diabetes could get their meal first. This helps the nurses coordinate the administration of insulin with the start of the meal. Rapid-acting insulin analogs allow for the flexibility of giving the insulin within 15 min before or just after the start of the meal.
It is the nurse’s responsibility to ensure that the patient is receiving the best meal plan for the primary diagnosis and all comorbidities to prevent persistent hyperglycemia. The nurse, working in concert with the dietitian, should assist the patient or their family in meal selection as the patient progresses from NPO to liquids, to soft foods, to the carbohydrate-controlled diet. Patients on clear or full liquid diets should receive ~200 g carbohydrates throughout the day divided into equal amounts and snack times. Nurses should let patients know that they will receive liquids that contain sugar on the clear liquid diet, such as regular gelatin and ginger ale to achieve the caloric requirements. Carbohydrates served on the controlled carbohydrate meal plan should be predominately from vegetables, legumes, fruit, whole grains, and low-fat dairy products.32 To reduce postprandial hyperglycemia, nurses should counsel patients to monitor the total carbohydrates eaten, which may include some sucrose-containing food choices in moderation. Many clinicians mistakenly believe that by prescribing a cardiac diet, it will include a restriction in carbohydrates and they neglect to order the diabetes meal plan. To prevent this, a change in order set may be needed. Consider including and preselecting the controlled carbohydrate meal plan in the insulin order set and allow for modifiers, such as cardiac or renal (see Table 34.3).
Table 34.3—Key Nutrition Recommendations for Diabetes and Glycemic Control in the Hospital
Nutrition therapy Implementation of nutrition therapy improves the care of patients with diabetes and hyperglycemia during hospitalization. RDs who are knowledgeable about glycemic control are the preferred team members to provide MNT.
Consistent-carbohydrate meal plan The consistent-carbohydrate meal plan is the established standard for hospitalized patients with diabetes and is useful to improve the accuracy of mealtime insulin administration. Evidence does not support the use of “no concentrated sweets” or “no sugar” diets. Sucrose-containing foods may be incorporated into a consistent-carbohydrate meal plan. The “ADA diet” is not current practice and should not be used. It may unnecessarily restrict calories and patients’ preferred foods. Since 1994, ADA has not recommended a specific type of diet or macronutrient distribution.
Liberalized diets Inadequate nutrition intake is common in hospitalized patients. To improve oral intake and enhance patients’ satisfaction, liberalized diets without caloric restriction (e.g., a general diet with consistent amounts of carbohydrate), room service on demand, and increased availability of foods that meet personal, cultural, or religious food preferences have been implemented in some acute-care facilities.
Coordination of meal delivery Diabetes educators and RDs are key interdisciplinary team members to improve coordination of meal delivery, insulin administration, and POC blood glucose monitoring to optimize glycemic control.
RD, registered dietitian; MNT, medical nutrition therapy; POC, point of care.
Source: Reproduced from Ryan.32
Parenteral (PN) and enteral (EN) feedings require special monitoring, careful nutrition formula selection, and diabetes medication adjustments. Because it is important that the formula provide both adequate nutrition and acceptable glycemic control, BGM may be needed on an ongoing basis even in patients who do not have diabetes.6 Insulin often is delivered according to calculated protocols, and dose adjustments should be considered daily. Protocol examples are available from the Society of Hospital Medicine.30
Insulin pump users and other patients who follow an intensive self-care insulin regimen during hospitalization may prefer a regular meal plan so that they can choose from a wider variety of foods and calculate their mealtime insulin dose using their insulin-to-carbohydrate ratio. A protocol should be in place that delineates the role of the patient and the nurse when performing self-care in pump users.18
Medication Management
Regardless of whether the patient has type 1 diabetes (T1D) or type 2 diabetes (T2D), maintaining glycemic control is a primary goal and a determinant in achieving positive health outcomes. The primary consideration when caring for patients with T1D is providing both basal and bolus insulin without interruption throughout the hospital stay. The preferred insulin regimen during hospitalization is scheduled basal and prandial insulin, in addition to supplemental correction insulin, if needed.33
In the hospital, oral antihyperglycemic agents should be discontinued because they lack the flexibility and efficacy needed in an acute-care setting and can present additional problems, such as drug interactions or abrupt changes in laboratory values. A long-acting sulfonylurea can promote hypoglycemia if a meal is delayed or the patient eats poorly. Biguanides, such as metformin, and thiazolidinediones are not recommended in times of impaired renal and hepatic function and fluid changes. Metformin must be discontinued before the day of any surgical procedure and should not be reinitiated for at least 48 h after the procedure. Oral antihyperglycemic agents and noninsulin injectables may be resumed close to or at the time of discharge (see Table 34.4).6,33
Table 34.4—Inpatient Medication Management of the Patient with Diabetes
Insulin Therapy
Aggressive initiation and intensification of insulin therapy often is required to achieve glycemic targets in acutely ill patients. The patient’s A1C, current glycemic control, weight, age, renal function, oral intake, and other medications ordered all should be taken into consideration. Intensive insulin management in an acutely ill patient often requires basal insulin (to cover metabolic needs), nutritional insulin to cover the carbohydrate in meals, enteral or parenteral nutrition, and supplemental insulin to correct hyperglycemia.18
No evidence supports the use of sliding-scale insulin regimens in the hospital setting. Sliding-scale insulin refers to the use of short- or rapid-acting insulin without basal insulin. When used alone, sliding-scale insulin therapy actually may promote hyperglycemia and glucose variability.33 Short-term use of supplemental or correctional insulin may be appropriate to correct hyperglycemia and evaluate insulin requirements in an insulin-naïve patient, especially if oral agents have been discontinued. Scheduled bolus, nutritional insulin, and supplemental or correctional insulin doses should be evaluated daily and adjusted to compensate for patterns of hyperglycemia or hypoglycemia and changes in eating status.
Many studies have shown improved outcomes in critical care when intravenous insulin infusion protocols are implemented to get to glycemic goals sooner and safer than with subcutaneous insulin.11–13 Many of these protocols are available online and from professional organization websites such as the AACE Inpatient Glycemic Control Center and the Society of Hospital Medicine (see Table 34.5).30,34 It is up to each institution to decide whether they choose to develop their own protocol, use or adapt a published protocol, or purchase a computerized program to assist the nurse in titrating the insulin drip rate based on current BG level and rate of change from the last BG reading.17,35
Table 34.5—Components of a Safe and Effective Insulin Infusion Protocol
• Includes appropriate glycemic targets
—Identifies threshold for implementation
—Is nurse-managed and easy to implement
—Provides clear, specific directions for blood glucose monitoring and titration
—Includes titration based on both current blood glucose level and rate of change*
—Is safe: carries a low risk for hypoglycemia and includes an embedded protocol for treatment of hypoglycemia should it occur
—Is effective: gets patients to target quickly and maintains blood glucose within the target range with minimal titration
—Includes a plan for transition to subcutaneous insulin
*Rate of change is calculated based on the slope of the blood glucose trend line and is frequently incorporated into column-based protocols by movement to a more aggressive algorithm if blood glucose is not declining by ~40–75 mg/dL or to a less aggressive algorithm if blood glucose is declining too rapidly.
Source: Reproduced from Kelly.36
The development of algorithms, protocols, and order sets will guide the less experienced clinician in achieving targets in a timely fashion with less hypoglycemia.4,5,18 Standing order sets for basal, bolus, and supplemental insulin and intravenous insulin drip protocols ensure that all providers aim for ideal goals as patients deal with the glucose level variations common during hospitalization. Scheduled basal and prandial insulin is the method of choice for subcutaneous insulin therapy.18 Correctional insulin may be combined with prandial insulin as a single injection; however, separating the orders may allow the nurse greater flexibility to assess whether or not the patient is eating and which insulin should be given each time. This method of management has become simpler and more seamless as more facilities adopt electronic medical record systems that offer dosing recommendations. Computerized prescriber order entry (CPOE) that includes weight-based subcutaneous basal and bolus insulin dosing that considers other factors, such as expected insulin sensitivity—for example, low dose (sensitive to insulin), medium dose (average), and high dose (resistant to insulin)—are being instituted in increasing numbers of facilities throughout the U.S.22,24 See Figure 34.1 for an example of a paper protocol and Figure 34.2 for an example of an electronic order set.
Figure 34.1—Subcutaneous insulin order set paper protocol.
Source: Reproduced from Society of Hospital Medicine.30
Figure 34.2—Subcutaneous insulin aspart glargine basal-bolus insulin standardized order set in computerized provider order entry (CPOE): low dose.
Source: Reproduced from New York–Presbyterian Hospital.37
Transitioning from Intravenous Insulin Drips to Subcutaneous Insulin
Once a patient’s condition begins to stabilize and the diet is advanced, intravenous insulin is no longer necessary. If not planned and implemented carefully, the transition from intravenous to subcutaneous insulin can cause a major disruption in glucose control and also can result in increased morbidity, such as triggering DKA in patients with T1D. Basal insulin should be given subcutaneously at a rate of 60–80% of the stable infusion dose 1–2 h before the intravenous insulin is discontinued.18 One option would be to discontinue the insulin drip just before a meal so that rapid-acting insulin also can be given. Careful monitoring of BG is important during the transition to detect hypo- or hyperglycemia.
Several studies in progress are examining the use of incretin agents, such as dipeptidyl peptidase 4 (DPP-4) inhibitors and glucagon-like peptide-1 (GLP1) receptor agonists in hospitalized patients. Because these agents stimulate glucose-dependent insulin production and therefore do not cause hypoglycemia, they may offer a more positive safety and efficacy profile than other agents in acutely ill patients.38
The nurse’s role in inpatient diabetes management beyond spearheading self-management education should include proactive attention to whether or not glycemic targets are being met and maintained during hospitalization. For example, bedside nurses can be educated and empowered to identify patients who are above agreed-on glycemic targets on their unit, review their nutritional intake and insulin orders, and notify prescribers of the need to initiate or intensify insulin therapy.10,39,40
Because diabetes frequently is diagnosed during hospitalization and acute illness increases the likelihood that insulin will be required, many patients with diabetes or hyperglycemia will go home on insulin for the first time. From the moment a patient starts receiving subcutaneous insulin injections on a daily basis in the hospital, the nurse should begin teaching self-administration. This may start with the nurse preparing the dose and the patient learning to self-inject to alleviate anxiety about the injection. Too often this step is overlooked, and the patient is given a rushed lesson moments before discharge with no opportunity to practice or gain confidence in their ability to perform the behavior in the home setting. Should patients actually go home not requiring insulin, they will have had a valuable experience and be capable of safe administration when the time comes. For patients with preexisting diabetes, hospitalization is an excellent opportunity to review survival skills and evaluate prior treatment regimens, modifying them if necessary. Even an experienced patient can still benefit from updating knowledge in a refresher session.
Practical Point
Nurses play a vital role in helping patients discover new ways to plan meals, be more active, take their medications correctly, and achieve and maintain glycemic control. Many opportunities exist for patient teaching during the hospital stay within the nurses’ work flow. Each time a BG check or insulin dose is needed, the patient or family should be involved as often as possible. Real-life challenges, such as meal and snack adjustments, interrupted meals, changes in diet, and episodes of hypoglycemia, all of which tend to occur more often in the hospital setting, provide opportunities for patient education. Every hospital nurse should learn about controlled-carbohydrate meal planning and healthy food choices so that patient questions can become a teachable moment (for more about healthy lifestyle choices, see Chapter 4, Nutrition Therapy: Healthy Eating and Regular Physical Activity).
Insulin Pens in the Hospital Setting
The use of insulin pens in the hospital setting offers the opportunity for nurses to teach patients how to use a pen before discharge and allow ample time for practice. At no time, however, should insulin pens be shared among patients, particularly in the hospital setting. Sharing pens, even if the pen needle is changed, is an unsafe practice that can lead to exposure to bloodborne pathogens. The Institute for Safe Medication Practices (ISMP) issued an alert several years ago advising hospitals to refrain from the use of insulin pens if they could not guarantee that sharing would not occur.41 At a 2015 insulin summit sponsored by ISMP, discussions about ways to increase the safety of insulin pens in the hospital addressed nursing education and patient-specific barcoding.
If an institution chooses to use only vial and syringe administration, insulin pen teaching kits can be used for patient education. Saline practice pens for demonstration purposes can be used to familiarize the patient with the mechanics of insulin pen use, such as attaching the pen needle and dialing an accurate dosage, helping the patient to acquire this skill before discharge. The saline practice pen is injected into a practice dome or pillow and cannot be used by the patient to self-inject. To learn self-injection skills, the patient will need to practice injection technique using an insulin syringe.
Management of Patients Using Own Insulin Pumps
More patients are using continuous subcutaneous insulin infusion (CSII) therapy (insulin pumps) than ever before, so having patients arrive in the hospital on an insulin pump is not unusual. If bedside nurses are not educated in pump therapy, an endocrinologist or a diabetes educator should be consulted to evaluate patient competency. If the patient is competent and wishes to continue pump therapy during hospitalization, both the patient and nurse responsibilities should be reviewed according to a written policy. Staff nurses should be instructed to assess the infusion site for any sign of infection or inflammation, provide a bedside flow sheet for the patient to keep records, document the patient self-report of carbohydrate intake and insulin taken in the medical record, and know how to disconnect the insulin pump if necessary. (For more information, see Chapter 26, Diabetes Technologies.) Because most bedside nurses are not familiar with insulin pump therapy, it is in the best interest of the patient that the hospital support a policy allowing the patient or family to maintain pump therapy as long as they are competent and willing to do so, and the patient does not require intravenous insulin (see Figure 34.3).
Insulin Pump Policy Nursing Documentation:
From: NYPH PATIENT’S OWN INSULIN PUMP POLICY- ADULT
H. Documentation
a) Nursing Notves: Document the following:
(1) Patient was admitted wearing insulin pump.
(2) Assessment of insulin pump insertion site upon admission and every shift.
(3) Site locations
(4) When witnessing change in reservoir, infusion set, site and hospital insulin supplied
(5) Episodes of hyper/hypoglycemia, pump and site problems and any interruptions in insulin delivery.
b) Vital Sign Flowsheet
(1) Blood glucose before meals and bedtime at minimum, add post meals during pregnancy. Note: Patient can use own BG meter to check BG at any time BUT the hospital meter must be used to determine insulin doses, treat hypoglycemia and for documentation in Eclipsys.
(2) Insulin pump boluses per patient report (create field in miscellaneous in Eclipsys) I. Instruct patient to notify RN immediately if they have any signs and symptoms of hypo/hyperglycemia.
J. Follow Hypoglycemia Assessment and Treatment Policy: Adult (non-pregnant) Policy (Hospital Policy: Medication Management P241) or Insulin Infusion during the Peripartum Period (Medication Use Manuel)
K. Hyperglycemia:
1) If the blood glucose is >250 mg/dL, patient is to give a corrective bolus dose. Repeat BG in 1 hour. If >250 mg/dL, call endocrine/maternal fetal medicine contact. Call prescriber to obtain an order for stat serum ketones.
2) At same time, instruct patient to check infusion set and pump; change infusion set if necessary. If pump malfunction, assist patient to call pump manufacturer’s toll free number to troubleshoot. NOTE: Toll free number is on back of insulin pump or back of remote control. If insulin delivery cannot be reestablished within 1 hour, notify endocrine/maternal fetal medicine contact.
Figure 34.3—Sample adult insulin pump policy nursing documentation.
Source: Reproduced from New York–Presbyterian Hospital.42
Because maintaining glycemic control plays a critical role in achieving positive health outcomes in acute care, the insulin delivery method that best accomplishes this goal should be supported by the patient’s care team. In some cases, maintaining pump therapy may not be feasible, and the hospital will need to transfer the patient to another method of insulin delivery.
Management of Hypoglycemia
Treating hypoglycemia in the hospitalized patient with diabetes is an essential nursing intervention. Hospitals should have written protocols for treating hypoglycemia that include recognition, specific treatment, and prevention. These protocols should indicate the glucose level at which treatment is initiated (usually <70 mg/dL) and the type and amount of glucose to be administered to patients who are able to swallow and are not NPO. If the patient is unable to take oral treatment, indications for the use of glucagon and intravenous dextrose should be clearly stated in the protocol. Certain circumstances may require that the prescriber be notified if the glucose level does not respond to the prescribed treatment to consider further action, such as starting a dextrose-containing intravenous infusion and lowering insulin doses (see also Chapter 9, Acute Complications of Diabetes).
Once 15 g of oral glucose is administered, the nurse should closely observe and assess the patient’s response to treatment. Many facilities treat with glucose only because of the variability in the amount of treatment when food is given and the length of time various foods take to absorb. Once a patient has an episode of hypoglycemia in the hospital, the risk increases for future events. An evaluation of the current insulin doses, nutritional intake, and any mismatches in the timing of the BG, insulin, and meal will help determine root causes.43
In hospitalized patients receiving intensive therapy for glycemic control, prevention of hypoglycemia should be an important goal. Rates of hypoglycemia should be tracked through POC testing data to identify areas in the hospital that would benefit from education in both treatment and prevention. Hypoglycemia often is preceded by a modifiable triggering event, such as a sudden change in caloric intake, transportation off the unit for a procedure, alteration in total parenteral or enteral nutrition, and hemodialysis. In addition, patients who are receiving antihyperglycemic medications and have certain conditions, such as renal insufficiency, advanced age, malnutrition, liver disease, septic shock, mechanical ventilation, total parenteral nutrition, congestive heart failure, stroke, malignancy, hypoglycemia unawareness, tapering steroids, or alcoholism, may be predisposed to hypoglycemic events.12,24,43,44
Patient Education
The bedside nurse is pivotal in the design and implementation of an individual education plan, which should begin early in the hospital stay to adequately prepare the patient for a safe discharge. Timely diabetes education can reduce length of stay and help prevent readmission.4,6,45 Bedside nurses, working collaboratively with a diabetes educator when available, have the greatest opportunity to provide diabetes self-management education in survival skills and assist the team in translating the hospital regimen into a regimen that the patient can support at home.46 These survival skills generally include self-monitoring of blood glucose (SMBG), basics of meal planning, medication taking, and hypoglycemia treatment and prevention.4,6,10,18 Other topics should be added when pertinent to the reason for admission, such as foot care and prevention of DKA. Whenever possible, the nurse should include patients in teaching sessions by having them participate in BG monitoring and insulin administration during the hospital stay. Family members should be included whenever possible so that they can assist patients at home as they recover from their acute illness, sharing the responsibilities and offering support. Nurses should abandon the practice of performing components of these skills away from the bedside where the patient cannot observe the technique. Patients who have a more challenging treatment regimen or who are having difficulty mastering skills will benefit from consultation with the diabetes educator or diabetes team while in the hospital. For example, menu selection and identification of carbohydrate-containing foods and portion sizes on the meal tray provide opportunities to practice skills. Consider a nutrition consult during the inpatient stay because it may be the patient’s only opportunity to meet with a dietitian. Patients should be provided with written instructions in a language they can read well whenever possible. Documentation in the medical record should include what was taught and whether the patient was able to perform the skill independently, needs practice, or lacks potential to master. The status of the survival skills education must be communicated to the care team to assist with discharge planning.6
Teaching acutely ill patients how to manage diabetes presents a greater challenge because the patient is likely to be fatigued and may be experiencing pain, nausea, or other complaints that would interfere with learning. Sessions are best kept short and focused on essential skills, and should include a demonstration and return demonstration.
Staff Education
All health-care professionals who care for patients with diabetes should receive glycemic management updates on an ongoing basis. This includes physicians, physician assistants, nurse practitioners, nurses, dietitians, pharmacists, and care coordinators.4 Diabetes educators can work with nurse educators to develop staff competencies, curricula, teaching checklists, and handouts to improve the nurse’s knowledge and confidence level in educating patients with diabetes. To accommodate the needs of the busy nurse, educational opportunities should be offered in a variety of ways, such as unit-based classes, continuing education programs, new staff orientation, self-learning modules including web-based programs, grand rounds, and mentoring programs.
Nursing education in survival skills education is a key strategy to facilitate patient teaching. Nurses should be knowledgeable about the current treatments for diabetes and understand how to teach patients to use devices that they will use at home. Resources should be made available to bedside nurses, such as sample home BG meters, saline insulin training pens, pen needles, practice cushions, and written materials. Some hospitals have made videos available through patient televisions and tablets that can be brought to the bedside.47 Apps and videos on tablets in the inpatient setting promote both innovative education and patient engagement. Many hospitals have created unit-based diabetes resource nurses or champions who receive additional education so that they can serve as the point person on their unit to mentor their peers when providing patient education and monitoring glycemic control. They often work collaboratively with the diabetes educator, disseminating new knowledge and resources to fellow clinicians.39,40
Survival Skills Education Topics in the Hospital Setting
• Key differences between T1D and T2D and how these differences relate to the patient’s current treatment plan
• BG monitoring techniques, pre- and postmeal targets, and interpreting results
• Basic understanding of carbohydrate-containing foods that are counted and appropriate portion sizes
• How patient’s current diabetes medications work and how they are taken safely and correctly
• Recognizing, treating, and preventing hypoglycemia and hyperglycemia
• Key follow-up appointments for diabetes medication adjustments and ongoing diabetes education
• Sick-day management, including when to call provider or go to the emergency department
Source: Adapted from Umpierrez6 and Seley.10
Patients with Preexisting Diabetes
Patients who have been self-managing their diabetes at home often are frustrated when they are admitted to the hospital and find they can take better care of their diabetes at home than staff can at the hospital. This further reinforces the need for hospital staff to be knowledgeable about current strategies to improve glycemic control and to make every effort to coordinate the timing of BG monitoring, insulin administration, and meal delivery so that patients are comfortable with the diabetes care they are receiving. Patients who are used to self-managing their disease find it difficult to relinquish control and trust the health-care team to make decisions that they are accustomed to making. Patients can be adamant about when and how much insulin they should be given, how often glucose should be monitored, and exactly what should be on their meal plan at every meal.
The best way for nurses to take advantage of the patient’s expertise is to accommodate the patient’s wishes as much as possible. When it is not possible to do so, detailed explanations about the care decisions and rationale will help the patient understand and agree to the treatment plan. An example of this is a patient who is on an insulin pump at home and is critically ill and needs to be on an intravenous insulin infusion. It is important to let the patient know that the rate of the intravenous infusion is monitored hourly and modified more aggressively than the patient’s own pump settings.
For the previously diagnosed patient, nurses should first assess the current level of knowledge of diabetes management and then should review, reinforce, and observe self-management skills. It is important to assess each patient’s learning needs and prior diabetes knowledge as early in the hospital admission as possible and to set mutual, realistic goals.4,10 Early assessment will provide opportunities to identify any barriers and identify available resources, such as a visiting nurse or a family member who can be taught skills needed for care at home. Never assume that patients are performing skills correctly just because they have been doing them for years. With cognitive and physical changes that can occur over time, especially during acute illness, and increasingly complex self-care regimens, the patient’s ability to perform these skills may have changed.
Patients New to Insulin
The patient with newly diagnosed T1D and many patients with T2D will need to begin insulin therapy while hospitalized. Although many patients with T2D do not depend on exogenous insulin for survival, many have decreased insulin production and require insulin for adequate BG control, especially during times of stress and illness. Patients should be informed of the progressive nature of T2D and know that the need for insulin is not a failure but rather a common sequela secondary to the exhaustion of β-cell function over time.
Although not ideal, the educational process may begin in the intensive care unit. Once the patient is stabilized, the remaining time spent in the hospital may be brief. The nurse should be alert to the patient’s progress and energy level and begin demonstrating insulin administration and SMBG as soon as the patient is able to participate even if it is just by observing the nurse. If family members are available, they should be included in these education sessions to support and assist the patient. The educational focus is on the survival skills needed to make the transition to the home setting. A home care referral may be needed to continue the education and reinforce diabetes self-management skills. All patients should be referred for outpatient diabetes self-management education. Diabetes self-management education is an ongoing process, and survival skills are only the beginning of what is needed by the patient to effectively manage diabetes at home.
Self-Management Education Programs
Both the Association and the AADE have information about self-management education programs on their websites at http://professional.diabetes.org/erp_list_zip and www.diabeteseducator.org. Also see www.diabetes.org and www.diabeteseducator.org for additional patient education materials.
When teaching patients about insulin administration, the goal is for the patient to understand and successfully discuss or demonstrate the following skills, with validation by the nurse:
• Insulin storage and preparation of injection
• Onset, peak, and duration of insulin
• Injection site selection, correct technique, site rotation
• Needle safety and disposal (disposal varies by state)
• Hypoglycemia symptoms, treatment, and prevention
For more on insulin administration, see Chapter 6, Treatment Strategies for Type 1 Diabetes.
Because patients are likely to be under increased stress and be fatigued secondary to acute illness, it is best to keep education sessions short.10 The focus should be on providing the immediate skills and knowledge that the patient needs to go home safely. Short, easy-to-read materials should be made available in multiple languages to reinforce education and ensure consistency from educator to educator. Simple one-page handouts available on the hospital infonet or short printed brochures help ensure that patients receive the same consistent information across settings from inpatient to outpatient. Brochures should contain basic information on survival skills, be printed in color, and provide some extra space for taking notes.
Transitional Care from Inpatient to Outpatient
Optimal discharge planning anticipates what the patient will need to continue diabetes self-management at home and should be initiated early in the stay to allow for adequate time to accomplish goals. When needs are anticipated early, patients (and their families) are better informed and more confident about how they will care for themselves at home. The nurse should coordinate with the interdisciplinary team members in planning care, teaching and reinforcing skills, and connecting with community resources for self-management support after discharge. Financial assistance and links to diabetes services and community resources helps minimize barriers and promotes successful diabetes self-management. Studies have shown that patients are at higher risk of readmission if they come from a minority group or are of lower socioeconomic status. Other risk factors include a history of readmission, having public insurance, and multiple comorbidities.48
Communication with the primary care provider or other diabetes providers is essential to ensure that a follow-up plan is in place for diabetes evaluation and medication adjustments.
The Transitional Care Model (TCM), developed by a multidisciplinary team at the University of Pennsylvania two decades ago, uses advanced practice nurses (APN) to follow high-risk chronically ill patients throughout hospitalization and into the community for up to 2 months. The APN guides the development of a patient- and family-centered plan of care, including self-management education, goal setting, coordination of visits with primary and specialty providers, and daily telephone availability. Studies utilizing the TCM model of care have yielded improved functional status and quality of life for the participants (see Table 34.6).23
Table 34.6—Ten Essential Features of the TCM
1. An apn is the primary coordinator of care throughout the entire episode of care to ensure consistency of the provider within and across settings.
2. Comprehensive assessment starts during the hospitilization to develop an evidence-based plan of care with the patient.
3. Regular home visits and telephone support (7 days/week) are provided by the APN through an average of 2 months after discharge.
4. The apn colloborates with older adults, family caregivers, and team members to implement a streamlined, evidence-based plan of care designed to promote positive health and cost outcomes.
5. Continuity of care between the hospital and follow-up with PCPs and specialists is facilitated by the APN through joint visits with the patients and physicians.
6. The model incorporates active engagement of patients and their family caregivers with a focus on education and support.
7. Emphasis is placed on patients’ early identification and response to symptoms and health-care risks to avoid adverse events contributing to acute service use (e.g., ED visits or rehospitalizations) and to acheive longer-term positive outcomes.
8. The model features a nurse-led multidisciplinary provider approach that includes patients and their family caregivers as part of a team.
9. Strong collaboration and communication occurs among patients, family caregivers, and the health-care team across the episode of care and in planning for the future (e.g., palliative care).
10. The institution provides ongoing investment in optimizing transitional care via performance monitoring and improvement. APN, advanced practice nurse; ED, emergency department.
Adapted from Transitional Care Model: Essential Elements. Available from http://www.transitionalcare.info/essential-elements. Accessed 30 May 2014.
Source: Reproduced from Hirschman.23
NEWLY DIAGNOSED T2D AND PREDIABETES
It is important that the hospitalized patient with newly diagnosed T2D or prediabetes have an understanding of the seriousness of the new diagnosis and the importance of follow-up with a health-care provider. The nurse should facilitate scheduling outpatient follow-up after discharge and provide the patient with the positive message that making healthy lifestyle choices now can improve long-term outcomes.
Diabetes educators may be available as a resource to guide this education, working collaboratively with the bedside nurse and other members of the team. All members of the team should be able to provide basic prediabetes and diabetes education to newly diagnosed patients. Documentation is important to facilitate communication among the team members to ensure that each member knows the status of the patient’s education plan and whether specific goals are being met. A brief, annual diabetes education course for nurses would be of great benefit to increase their knowledge and comfort level in providing basic diabetes education to patients.
Patients with Self-Management Problems
Patients who struggle with taking care of their diabetes at home present an additional nursing challenge. The hospitalization may be a good time to talk to patients about their difficulties following the diabetes regimen, commending them for what they do accomplish, and learning what needs to be addressed. Open communication may allow the nurse to assist the patient in identifying barriers that may be preventing optimal self-care and coming up with possible solutions. Lack of financial resources and reimbursement may be preventing self-care, especially medication taking and sufficient BG monitoring to identify patterns and make informed medication adjustments. In these cases, a referral to a social worker as well as identification of any patient assistance programs available through the pharmaceutical companies will be key factors in reducing the financial barriers to treatment.
A consultation with a diabetes educator or dietitian may be helpful, but this should not replace the opportunity for nurse–patient interaction at the bedside. Education with every medication administration, discussion of POC BG results, careful explanation of all diagnostic tests, assistance with food choices from the hospital menu, and solicitation of support from family and friends can all send the message to the patient that diabetes control is both important and possible.
SUMMARY
Because 29.3 million Americans have diabetes and another 86 million have prediabetes, hospital nurses across all units and services need to be proficient in caring for people with diabetes and hyperglycemia.49 Nursing education should include diabetes self-care management and education strategies as well as specific protocols that guide the treatment of hypo- and hyperglycemia in acutely ill patients.
To promote safe use of insulin in the hospital setting, glycemic management protocols, order sets, and treatment algorithms should be available for insulin infusions, subcutaneous insulin initiation and titration, hypoglycemia, hyperglycemia, DKA, and HHS. Clinical pathways should be developed, implemented, and evaluated to guide best practices for caring for the hospitalized patient with diabetes.30,34,50 In a Society of Hospital Medicine survey of best practices in 19 hospitals in the U.S., two of the keys for success identified were the development of interdisciplinary care teams and identification of strategies to improve glycemic control. Although most teams reported having protocols for basal-bolus subcutaneous insulin, intravenous insulin infusions, and hypoglycemia treatment, they lacked standardization and coordination of staff and patient education, quality metrics, care delivery, and discharge planning (see Table 34.1).
When diabetes management is considered a priority in the treatment of other acute medical problems, outcomes are improved and hospital stays are shortened.6 Studies have provided supporting evidence showing the importance of glycemic control during acute illness and the need to set glycemic goals. This valuable information should be incorporated into the clinical practice of all members of the health-care team to improve outcomes and quality of life for patients with diabetes or hyperglycemia.
Recommendations
• Consider performing an A1C on all patients with diabetes or hyperglycemia admitted to the hospital if not performed in the prior 3 months.
• Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold 180 mg/dL (10.0 mmol/L). Once insulin therapy is started, a target glucose range of 140–180 mg/dL (7.8–10.0 mmol/L) is recommended for the majority of critically ill patients and noncritically ill patients.
• More stringent goals, such as <140 mg/dL (6.1–7.8 mmol/L) may be appropriate for selected critically ill patients, as long as this can be achieved without significant hypoglycemia.
• Intravenous insulin infusions should be administered using validated written or computerized protocols that allow for predefined adjustments in the insulin infusion rate based on glycemic fluctuations and insulin dose.
• A basal plus bolus correction insulin regimen is the preferred treatment for noncritically ill patients with poor oral intake or those who are taking nothing by mouth. An insulin regimen with basal, nutritional, and correction components is the preferred treatment for patients with good nutritional intake.
• The sole use of sliding-scale insulin in the inpatient hospital setting is strongly discouraged.
• 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 medical record and tracked.
• The treatment regimen should be reviewed and changed if necessary to prevent further hypoglycemia when a BG value is <70 mg/dL (3.9 mmol/L).
• A structured discharge plan should be tailored to the individual patient.
Source: From the American Diabetes Association.18
Patient education in survival skills should be looked upon as an essential responsibility of the hospital nurse and incorporated into the nurse’s work flow. It should not create an additional burden to the busy nurse if it is performed as part of daily routines. Inpatient diabetes management is a team effort. Nurses are important members of the team, with many opportunities to improve patients’ glycemic control and the delivery of diabetes care and education in preparation for discharge.
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