Module 3Initial Recognition, Triaging, and Management of Hyperglycemia

Diabetes Special Interest Group

Georgia Hospital Association

The highlighted topic is what is covered in this module

Learning Modules

Module no. Topic

1 Hyperglycemia and hospital outcomes

2 Challenges and opportunities for care improvement

3 Initial recognition, triaging, and management

4 Principles of pharmacologic management: Insulin 1

5 Principles of pharmacologic management: Insulin 2

6 Review of policies and procedures

7 Getting patient ready for discharge

Summary Of Key Points From Previous Modules

• The numbers of diabetes cases seen in the hospital are rising

• Hyperglycemia in the hospital is associated with worse patient outcomes

• Controlling glucose in the hospital can lead to better patient outcomes

• There is room to improve diabetes care at most facilities

With this module we will begin to discuss management strategies

Module 3 Objectives• Understand the phases of inpatient glucose

management• Differentiate types of hyperglycemic patients

you will encounter in the hospital• Initiate appropriate management steps

according to:– Type of diabetes– Severity of hyperglycemia

Phases of Inpatient Hyperglycemia Care

Admission

First 24 hours Continued care

Recognition and triageInitial treatment plan

Ongoing monitoringEducation

Treatment adjustment

Discharge planning

What therapy?What is the follow-up?

Do patients knowwhat to do?

Education provided?

This module will focus on the first 24 hours of management

We will conceptually divide inpatient hyperglycemia care into three phases

Types of Hyperglycemic Patients in the Hospital

Patients with pre-existing diabetes• Have a history of diagnosed diabetes• May be on pharmacotherapy

Patients with stress hyperglycemia• Hyperglycemia that develops in response to the acute illness or medications• Require therapy during hospital stay if their blood glucose is above target range for their unit (ICU 80-110 mg/dL, Med Surg and Peri-Op 90-140 mg/dL

Patients with undiagnosed diabetes• Often have unequivocal hyperglycemia (glucose 200 mg/dL) on admission

Minimum Admission Actions• Patients with diabetes/hyperglycemia, or who

are at risk of developing hyperglycemia (e.g. transplant patients, patients starting steroids) should have at admission a minimum:– Bedside glucose monitoring ac, hs, & 3AM if eating

or every 6 hours if NPO– Hemoglobin A1c if none available from past 60 days– Documentation in admission note about the presence

or risk of hyperglycemia– Therapeutic strategy outlined

Remember to include the problem of diabetes/hyperglycemia in your problem list!

Initial Management Decisions

Should be based on the type of diabetes and severity of hyperglycemia

Half of the patients with diabetes are undiagnosed.

Patients without a known diagnosis of diabetes but who exhibit hyperglycemia on admission likely have diabetes and should

be treated as such.

Triaging Patients Without Known Diabetes

*All insulin deficient patients, especially type 1 diabetes, must have insulin

Patient admitted

DKAHyperglycemic CrisisLabor and Delivery

No previous Diabetes DiagnosisElevated Admission Glucose

<200 mg/dL

Obtain HbA1c, Begin BG Monitoring, Correct with rapid Insulin any BG > 140 mg/dL

Bedside glucose 140 mg/dL two consecutive measurements

Unequivocal hyperglycemia(glucose 200 mg/dL, not

DKA/hyperglycemic crisis or labor)

Obtain HbA1cBegin glucose monitoring

Start scheduled insulin therapy

Obtain HbA1cBegin IV Insulin Protocol

Glucose Monitoring Hourly

Bedside glucose occasionally140 to 199 mg/dL

Start basal-bolus insulin protocolConsult diabetes education team

Continue to monitorStart correctional insulin

Consider basal bolus in cardiac pts.

Patient admitted

Determine if insulin requiring

Type 1 orInsulin Requiring

Type 2 or Gestational

Type 2 Diabetes or Gestational Not Using

Insulin

Obtain HbA1cStart monitoring

Continue and adjust insulin regimen

Was taking oral agents*

Obtain HbA1cStart monitoring

Start insulin if needed

No previouspharmacotherapy

Obtain HbA1cStart monitoring

Start insulin if needed

*Should usually be discontinued in acutely ill patients

Initial Management for Patients With Known Diabetes

Case Scenario

• A 75 year old lean woman with a 5 year history of diabetes is admitted for elective knee replacement. She has always needed insulin to control hyperglycemia. She is currently on short acting insulin with meals and a long acting insulin in the evening. You place her only on a sliding scale program. Her blood glucoses start to rise pretty quickly into 300’s and 400’s, and you desperately call the Endocrine service. What went wrong?

She has Type 1 Diabetes and needs a basal – bolus insulin program.

Not every person who develops diabetes in older years has Type 2 diabetes. Be certain to correctly classify your patient’s diabetes and never withhold basal insulin from someone with Type 1 diabetes.

When a patient with pre-existing diabetes is admitted to the hospital…

• Determine if they are insulin requiring– Type 1 Diabetes patients ALWAYS need a long

acting (basal) insulin even if they are fasting. They also need meal bolus insulin based on the carbohydrate they consume at each meal.

• If patients are already on outpatient insulin, chances are they were on it because they needed it—at the very least keep them on basal insulin until you are sure they don’t

need it

Module Summary

• Hyperglycemic inpatients are diverse—be sure you know who you are managing

• Identify hyperglycemic patients early• Apply appropriate therapy early