Focus on Inpatient Diabetes Management: Optimizing Glycemic Control

Optimizing glycemic control in the inpatient setting is critical. In the ICU, target blood glucose (BG) levels should be <110 mg/dL. In the non-ICU inpatient setting, the level may vary, since patients are likely to be eating, but the BG levels should never exceed 180 mg/dL. Maintaining control has been challenging due to the widespread practice of sliding scale orders. Experts suggest that sliding scale orders are ineffective and compromise therapy, and their use promotes a reactive, rather than proactive approach to achieving target BG levels. In fact, a study from the University of Colorado has shown that 80% of initial sliding scale orders are never changed. Unwanted consequences associated with sliding scale orders include extreme variability in BG levels, a higher incidence of hypoglycemia, and in type 1 patients, diabetic ketoacidosis. Elimination of sliding scale orders as a standard practice could significantly improve outcomes in hospitalized patients with hyperglycemia.

The way to achieve target BG levels in the hospital setting is by using a basal insulin program. Many inpatients with hyperglycemia require continuous insulin infusions, especially if they are in a ketoacidotic or hyperosmolar state, if they are on steroids, or if they have recently undergone surgery. There are several protocols that provide guidance for continuous insulin infusion in the hospital setting, including guidelines from the American College of Endocrinology.

Transitioning a patient with hyperglycemia from the ICU to a non-ICU setting in the hospital is an area of concern. One method that can be used to facilitate this transition is going back to a basal/bolus regimen and calculating insulin needs based on the continuous insulin infusion regimen that was used prior to the transition out of the ICU. The basal/bolus approach will also be useful when patients are eating meals, instead of receiving nutrition intravenously. Overall, controlling hyperglycemia in the inpatient setting should be a multidisciplinary team effort, with medical and nursing staffs, the pharmacy, and the patient all playing key roles.

In this conversation, Dr. Andrew Ahmann and Dr. Etie Moghissi join Dr. Carlos Hamilton to discuss issues related to optimizing glycemic control in the inpatient setting.

Related References/Reading:

1. American College of Endocrinology. Position Statement on Inpatient Diabetes and Metabolic Control. Endocrine Practice. 2004;10:77-82.
2. Furnary AP, Gao G, Grunkmeier GL, et al. Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. J Thoracic Cardiovasc Surg. 2003;125:1007-21.