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Module 3
Initial Recognition, Triaging, and
Management of Hyperglycemia
Diabetes Special Interest Group
Georgia Hospital Association
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
The highlighted topic is what is covered in this module
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
We will conceptually divide inpatient hyperglycemia care into three phases
Admission
First 24 hours
Recognition and triage
Initial treatment plan
Continued care
Discharge
planning
Ongoing monitoring
Education
Treatment adjustment
What therapy?
What is the follow-up?
Do patients know
what to do?
Education provided?
This module will focus on the first 24 hours of management
Types of Hyperglycemic
Patients in the Hospital
Patients with pre-existing diabetes
• Have a history of diagnosed
diabetes
• May be on pharmacotherapy
Patients with undiagnosed diabetes
• Often have unequivocal
hyperglycemia (glucose 200 mg/dL)
on admission
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
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
Patient admitted
DKA
Hyperglycemic Crisis
Labor and Delivery
Elevated Admission Glucose
<200 mg/dL
Unequivocal hyperglycemia
(glucose 200 mg/dL, not
DKA/hyperglycemic crisis or labor)
Obtain HbA1c
Begin IV Insulin Protocol
Glucose Monitoring Hourly
Obtain HbA1c, Begin BG
Monitoring, Correct with rapid
Insulin any BG > 140 mg/dL
Obtain HbA1c
Begin glucose monitoring
Start scheduled insulin therapy
No previous Diabetes Diagnosis
Bedside glucose 140 mg/dL
two consecutive
measurements
Start basal-bolus insulin protocol
Consult diabetes education team
Bedside glucose occasionally
140 to 199 mg/dL
Continue to monitor
Start correctional insulin
Consider basal bolus in cardiac pts.
*All insulin deficient patients, especially type 1 diabetes, must have insulin
Initial Management for Patients
With Known Diabetes
Patient admitted
Determine if
insulin requiring
Type 1 or
Insulin Requiring
Type 2 or Gestational
Obtain HbA1c
Start monitoring
Continue and adjust
insulin regimen
Type 2 Diabetes or
Gestational Not Using
Insulin
Was taking
oral agents*
No previous
pharmacotherapy
Obtain HbA1c
Start monitoring
Start insulin if needed
Obtain HbA1c
Start monitoring
Start insulin if needed
*Should usually be discontinued in acutely ill patients
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