Management Of Inpatient Hyperglycemia Research Articles

Impact of inpatient management of hyperglycemia on peripheral T cell markers in patients with type 2 diabetes.

The online version contains supplementary material available at 10.1007/s13340-024-00697-7.

Inpatient glycemic management in noncritically ill patients: Updated guidelines.

Hyperglycemia is common in hospitalized patients and is traditionally managed with scheduled and correctional doses of insulin. The authors present an overview of the latest (2022) guidelines from the Endocrine Society on inpatient hyperglycemia management in noncritically ill patients, which includes a role for newer diabetes technologies and nontraditional insulin and noninsulin therapies.

1019-P: Implementation Analysis of Pharmacist-Managed Insulin Dosing in an Acute Care Hospital

Hyperglycemia is associated with negative health outcomes such as increased infection, increased thrombosis, decreased wound healing and prolonged hospitalization. The 2022 ADA guidelines for hospitalized patients recommend targeting blood glucose (BG) 140-180 mg/dL in both critically and non-critically ill patients and managing persistent hyperglycemia with insulin. Data evaluating the impact of a pharmacist-managed insulin dosing protocol is currently lacking. The objective of this study was to evaluate the safety and efficacy of a pharmacist-managed basal-bolus (BB) insulin dosing protocol for inpatient hyperglycemia management. This single-center, retrospective, observational study included patients > 18yo with three consecutive BG concentrations 180-350mg/dL admitted to the critical care, telemetry, and medical/surgical floors. The insulin per pharmacy dosing protocol was implemented in December 2020. A total of 494 patients were included in the pre-implementation group (January-November 2020) and 668 patients in the post-implementation group (July-December 2021). No significant difference in baseline characteristics were observed between the two groups. For primary outcome, post-implementation group had a statistically significant higher percentage of normoglycemia defined as BG 70-180 mg/dL (63.4% vs. 50.2%, p<0.01) and a statistically significant lower percentage of hyperglycemia defined as BG >180 mg/dL (35.1% vs. 48.2%, p<0.01). No difference in hypoglycemia rate between the two groups were observed (1.6% vs. 1.5%, p>0.1) confirming protocol safety. For secondary outcome, no difference in average length of stay between the two groups, although goal BG<180 mg/dL was achieved on day 2 in post-implementation group vs. day 6 in pre-implementation group. This study suggests that pharmacists can effectively and safely manage inpatient hyperglycemia in both critically ill and non-critically ill patients utilizing a standardized BB insulin dosing protocol. Disclosure A.G.Hadiprodjo: None. E.M.Scott: None. R.Weng: None.

COMPLETE AUDIT CYCLE: PERI-OPERATIVE GLYCEMIC CONTROL IN CMH LAHORE

Hyperglycemia is associated with an increased risk of complications in patients undergoing surgery. Hyperglycemia from diabetes must be differentiated from stress-induced hyperglycemia, which typically presents post-operatively and resolves as the surgery-induced stress subsides. It is imperative to differentiate between the two due to the severe complications of diabetic hyperglycemia, which can often be confused with its stressed induced counterpart. Good glycemic control is the best strategy to avoid post-operative complications and morbidity. An assessment of peri-operative blood glucose levels of known diabetics admitted to CMH Lahore was done, and recommendations were introduced to achieve better glycemic control. Subsequently preventing post-surgical complications, improving wound healing and overall recovery, and ultimately decreasing morbidity. The aim of the audit was the assessment of peri-operative glycemic control in known diabetics admitted for surgery in CMH Lahore. Existing problems regarding poor glycemic control were identified, and recommendations were given to rectify said problems. We aimed to study the effectiveness of glucose control due to these planned interventions. Patients were included based on eligibility criteria, and a record of the patients was updated daily on the Excel sheet using the glucose control audit tool (attached below). The highest BSR reading per day was added. Good or poor glycemic control was determined by the highest BSR readings on post-op days 0, 1, and 2. If 2 or more readings met the criteria for good glycemic control, the patient was labeled to have good glycemic control. In Cycle 1, patients were managed peri-operatively with insulin as per the sliding scale. 13% of patients had good glycemic control on this regimen. Interventions were introduced for Cycle 2, with the recommendation of altering insulin/drug regimens as per NHS/ADA guidelines. 16.6% of patients were found to achieve good glycemic control; however, it was noted that these recommendations were not followed consistently. Based on the results, it can be concluded that the management of inpatient diabetes is a team effort, interventions recommended using established guidelines should be followed stringently, and existing protocols should be updated accordingly. Proper management of inpatient hyperglycemia starts with each team member performing their respective role to their best; this is vital in preventing post-operative complications associated with poor glycemic control.

A Novel Algorithm for the Management of Inpatient COVID-19 Glucocorticoid-Induced Hyperglycemia.

Hyperglycemia in hospitalized patients with coronavirus disease 2019 (COVID-19) is linked to increased morbidity and mortality. This article reports on a novel insulin titration protocol for the management of glucocorticoid-induced hyperglycemia in hospitalized patients with COVID-19. Sixty-five patients with COVID-19 and glucocorticoid-induced hyperglycemia admitted after the protocol implementation were matched 1:1 to patients admitted before the treatment protocol rollout for analysis. In a large, diverse health system, the protocol achieved reductions in hypoglycemic events without increasing hyperglycemia or insulin use.

Hyperglycemia in COVID-19 infection without diabetes mellitus: Association with inflammatory markers.

New onset hyperglycemia is common in patients with severe coronavirus disease 2019 (COVID-19) infection. Cytokine storm due to COVID-19 infection is an essential etiology for new-onset hyperglycemia, but factors like direct severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-induced pancreatic β-cell failure have also been postulated to play a role. We plan to investigate further the mechanisms underlying SARS-CoV-2 infection-induced hyperglycemia, particularly the rationale of the cytokine-induced hyperglycemia hypothesis, by evaluating the association between inflammatory markers and new onset hyperglycemia in non-diabetic patients with COVID-19 infection. We conducted a retrospective case-control study on adults without diabetes mellitus hospitalized for COVID-19 infection. The serum levels of glucose and inflammatory markers at presentation before initiation of corticosteroid were collected. Hyperglycemia was defined as glucose levels ≥ 140 mg/dL. C-Reactive protein (CRP) ≥ 100 mg/L, ferritin ≥ 530 ng/mL, lactate dehydrogenase (LDH) ≥ 590 U/L, and D-dimer ≥ 0.5 mg/L were considered elevated. We used the χ 2 test for categorical variables and the Mann-Whitney U test for continuous variables and calculated the logistic regression for hyperglycemia. Of the 520 patients screened, 248 met the inclusion criteria. Baseline demographics were equally distributed between patients with hyperglycemia and those who were normoglycemic. Serum inflammatory markers in patients with or without new-onset hyperglycemia were elevated as follows: CRP (58.1% vs 65.6%, P = 0.29), ferritin (48.4% vs 34.9%, P = 0.14), D-dimer (37.1% vs 37.1%, P = 0.76) and LDH (19.4% vs 11.8%, P = 0.02). Logistic regression analysis showed LDH odds ratio (OR) = 1.623 (P = 0.256). We observed significantly higher mortality (24.2% vs 9.1%, P = 0.001; OR = 2.528, P = 0.024) and length of stay (8.89 vs 6.69, P = 0.026) in patients with hyperglycemia. Our study showed no association between CRP, ferritin, LDH, D-dimer levels, and new-onset hyperglycemia in non-diabetic patients with COVID-19 infection. It also shows an increased mortality risk and length of stay in patients with hyperglycemia. With new-onset hyperglycemia being closely associated with poor prognostic indices, it becomes pivotal to understand the underlying pathophysiological mechanisms behind the SARS-CoV-2 infection-induced hyperglycemia. We conclude that the stress hyperglycemia hypothesis is not the only mechanism of SARS-CoV-2 infection-induced hyperglycemia but rather a multicausal pathogenesis leading to hyperglycemia that requires further research and understanding. This would help us improve not only the clinical outcomes of COVID-19 disease and inpatient hyperglycemia management but also understand the long-term effects of SARS-CoV-2 infection and further management.

PSUN224 Resident Education for Improved Quality and Confidence in Inpatient Hyperglycemia Management

Abstract Background Hyperglycemia is widely prevalent in hospitalized patients and has been associated with adverse outcomes and increased mortality. Guidelines for inpatient management of hyperglycemia in non-critically ill adults are inconsistently implemented within our hospital system in a large academic center in New York. Thus, we strove to develop a formal curriculum for our internal medicine program to improve the level of confidence in trainees when managing inpatient hyperglycemia and to promote appropriate subspecialty consultation. Methods We designed a three-phase educational curriculum for internal medicine residents of all training levels. The first phase consisted of a pre-intervention questionnaire distributed online, examining the self-reported level of confidence and knowledge of hyperglycemia management in non-critically ill patients. The second phase consisted of a 50-minute lecture providing background on the prevalence and risk of inpatient hyperglycemia, standard guidelines for inpatient hyperglycemia management, appropriate insulin regimen initiation and adjustment and practice questions reviewed in real time. The third phase consisted of an online post-intervention questionnaire which, in addition to reassessing confidence and knowledge, examined change in individual confidence level in hyperglycemia management and the ability to recognize situations appropriate for endocrinology consultation. In the context of convenience sampling, all residents were eligible to participate in the second questionnaire independent of their participation in the first questionnaire or educational intervention. Results There were 57 total respondents for the pre-intervention questionnaire and 54 total respondents for the post-intervention questionnaire. 26 (48%) of the post-intervention questionnaire respondents completed the initial questionnaire and 22 (41%) attended the lecture. In examining confidence in managing inpatient hyperglycemia on a four-level scale (not comfortable, somewhat comfortable, comfortable, and very comfortable), there was an overall increase in percentage of "comfortable" responses (26% to 52%) with a subsequent decrease in "somewhat comfortable" responses (65% to 37%) when comparing post- to pre-intervention questionnaires. In addition, there was a higher percentage of "comfortable" responses in those who attended the lecture versus those who did not (59% vs. 47%). Furthermore, 21 of the 22 respondents who attended the lecture felt "more confident" in their ability to treat inpatient hyperglycemia. Lastly, those who attended the lecture were more likely to identify situations in which endocrinology should be consulted. Conclusion Currently, there is no formal longitudinal curriculum established for resident education in inpatient diabetes care and hyperglycemia management. The objective of this intervention was to identify and bridge the gap in practical knowledge and confidence level across all training levels. In a small sample size of residents, data revealed higher confidence in management and ability to recognize the necessity of endocrinology consults. Future research will focus on analyzing concrete data in a target unit to assess translation of the intervention to improved quality of inpatient glycemic control. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

LBSUN209 A Novel Algorithm For The Management Of Inpatient Covid-19 Steroid-induced Hyperglycemia

Abstract Objective/Background Hyperglycemia in hospitalized patients with COVID-19 is linked to increased morbidity and mortality. With increasing use of glucocorticoid (GC) therapy for COVID-19 hypoxemia, clinicians are challenged with an increased prevalence of hyperglycemia. Methods We developed an insulin protocol to aid front line providers in the management of GC-induced hyperglycemia for hospitalized adults with COVID-19. The protocol was based on expert opinion and was available from March 2021 onward. Glycemic and clinical outcomes were obtained for patients treated with GC and retrospectively compared to historical controls treated with GC admitted up to 6 months prior to protocol implementation. Glycemic parameters for finger stick glucose values (FSG) were defined as hypoglycemia <70 mg/dL, euglycemia 70-180 mg/dL, mild hyperglycemia 180-250 mg/dL and severe hyperglycemia >250 mg/dL. To account for differences in the quantity of total FSG between groups, we adjusted for length of stay and calculated the proportion of FSG per patient. Results 130 patients with COVID-19 and GC induced hyperglycemia from before (n=65) and after (n=65) protocol implementation were matched 1: 1 based on age, weight, and sex. There were no significant differences in other baseline patient characteristics. Significantly more patients in the protocol group had mean FSG in the euglycemic range (16.9% vs 38.5%, p=0. 006), and there was a decrease in patients with mean glucose in the mild hyperglycemia range that trended toward significance (50.8% vs 35.4%, p=0. 076). The protocol group had a significantly lower proportion of hypoglycemic FSG per patient (0. 003 vs 0. 008, p=0. 044). Patients in the protocol group had more euglycemic FSG per patient, but this did not reach significance (0.413 vs 0.350, p=0.239). Similarly, the proportion of mild hyperglycemic FSG per patient trended lower in the protocol group (0.315 vs 0.272, p=0.291). There were no significant differences in severe hyperglycemia per patient (0.311 vs 0.328, p=0.828). The protocol group had a significantly higher utilization of basal-bolus insulin regimen (n=43 vs n=63, p<0. 0001) with an increase percentage of bolus insulin utilization in peak total daily dose (70.2% vs. 62.4%, p=0. 08). Total peak day insulin dose trended lower in the protocol group (0.25 vs 0.32 U/kg, p=0.36). Conclusion A novel insulin protocol for the management of GC-induced hyperglycemia in hospitalized COVID-19 patients is an effective tool to achieve reductions in hypoglycemic events and higher utilization of standard of care basal-bolus insulin regimens without increased hyperglycemia or total daily dose of insulin. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

140-LB: Management of Inpatient Hyperglycemia Guided by Continuous Glucose Monitoring (CGM) in Insulin-Treated Patients with Diabetes—A Randomized Clinical Trial

Inpatient use of CGM results in higher detection of hypoglycemic and hyperglycemic events compared to point of care testing (POC) but its efficacy and safety in adjusting insulin therapy has not been evaluated. This randomized controlled trial included 181 general medicine and surgery patients with type 1 (n= 18) and type 2 (n= 155) diabetes treated with a basal bolus insulin regimen. All patients underwent POC testing AC & HS. Patients in the POC group wore a blinded Dexcom G6 CGM with insulin dose adjusted based on POC results; while in the CGM group, insulin adjustment was based on daily Dexcom G6 CGM profile review. Hypoglycemia alarms were set at 80 mg/dl in the CGM group. Primary endpoints were differences in time in range (70-180 mg/dl) and hypoglycemia (<70 mg/dl and <54 mg/dl) . Results: There were no differences on admission clinical characteristics, HbA1c or diabetes type between POC and CGM groups. There were no differences in mean daily glucose (186.8±39 mg/dl vs. 183.2±40 mg/dl, p=0.36) , total daily insulin dose (36.1±28 U/day vs. 40.7±29 U/day, p=0.33) , % patients with CGM values <70 mg/dl (39% vs. 36%, p=0.68) or <54mg/dl (24% vs. 14%, p=0.12) between the two groups. Among patients with ≥ 1 hypoglycemic event, compared to POC, CGM use resulted in significant reduction in hypoglycemia recurrence with an incidence-ratio for glucose <70mg/dl (0.53, 95% CI:0.31-0.92) and incidence-ratio for glucose <54mg/dl (0.37 (95% CI:0.17-0.83) . The percent time <70 mg/dl among those with hypoglycemia was smaller in the CGM (1.9±3.3% vs. 5.5±8.5, p=0.024) compared to the POC group, with group difference in hypoglycemia confirmed by zero-inflated Beta Regression analysis (p<0.001) . Conclusion: Our results indicates that the inpatient use of Dexcom G6 CGM is safe and effective in guiding insulin adjustment resulting in similar improvement in glucose control and in significant reduction of recurrent hypoglycemic events compared to POC testing. Disclosure I. Spanakis: Other Relationship; Dexcom, Inc. L. G. Singh: None. C. Gothong: None. I. Marcano: None. S. Lizama: None. K. M. Munir: None. C. Chesney: None. R. D. Maguire: None. W. H. Scott: None. L. Peng: None. G. E. Umpierrez: Research Support; AstraZeneca, Dexcom, Inc., Novo Nordisk. M. A. Urrutia: None. M. F. Scioscia: None. R. J. Galindo: Advisory Panel; Sanofi, WW International, Inc., Research Support; Dexcom, Inc., Eli Lilly and Company, Novo Nordisk. P. Vellanki: n/a. A. L. Migdal: None. G. Davis: Consultant; Medscape, Research Support; Insulet Corporation. T. Idrees: None. F. J. Pasquel: Consultant; AI Health LLC, Boehringer Ingelheim International GmbH, Dexcom, Inc., Research Support; Dexcom, Inc., Insulet Corporation, Merck & Co., Inc.

Guidance for the management of inpatient hyperglycemia in COVID-19

Diabetes and hyperglycemia are among the most common problems in hospitalized patients, a combination particularly evident in patients affected by COVID-19. Therefore the management of these, already complex, patients becomes critical. SARS-CoV2 infection increases insulin resistance and alters its production by pancreatic beta-cells, therefore severe hyperglycemia is frequent in patients admitted to COVID hospitals both already suffering from Diabetes mellitus or dysglycemia, and in those without known alterations of glucose metabolism. High-dose glucocorticoid treatment, frequently used in more complex COVID-19, also alters glucose metabolism, thus worsening hyperglycemia. Consequently, severe hyperglycemia is frequent, both in the admission phase and during hospitalization of COVID-19 in patients, and therefore, although the care and assistance of COVID-19 inpatients is complex, treatment of hyperglycemia cannot be underestimated. It has indeed been demonstrated that glucose levels above 180 mg/dL are known to be linked to increased mortality and worse prognosis of inpatients. In addition, people with diabetes are at a higher risk of serious COVID-19. The aim of this work was to offer to healthcare professionals involved in the care of COVID inpatients a support in making clinical decisions for the management of hyperglycemia, so to ensure both appropriate blood glucose surveillance and hyperglycemia management avoiding improper use of precious resources. Therefore, the Inpatient project group has developed easy-to-consult flow charts available on the AMD website during the COVID-19 pandemic second wave. KEY WORDS management of hyperglycemic crises; inpatients with COVID-19; glucocorticosteroid therapy.

Clinical Effectiveness of a Protocol to Manage Deamthasone-Induced Hyperglycemia Among Hospitalized Patients With COVID-19

Importance: Well-controlled glucose levels during hospitalization (i.e. 70–180 mg/dl) have been associated with lower mortality in patients with COVID-19. The recent addition of dexamethasone to COVID-19 treatment protocols has raised concerns about the negative metabolic consequences of dexamethasone including hyperglycemia. We developed a simplified, yet comprehensive, protocol to guide the management of dexamethasone-induced hyperglycemia in hospitalized patients with COVID-19. Objectives: To present our protocol for the management of dexamethasone-induced hyperglycemia and examine its clinical effectiveness in the real world. Methods: An algorithm-based protocol that outlines all aspects of the inpatient management of dexamethasone-induced hyperglycemia in COVID-19 patients, from time of admission to discharge including guidance on insulin titration, was disseminated to the COVID-19 teams in our hospital. Medical records of 163 patients admitted between June and September, 2020 who tested positive for COVID-19 and developed dexamethasone-induced hyperglycemia were reviewed. Fasting, pre-lunch, pre-dinner and bedtime glucose levels during the first five days of admission and day of discharge were compared between the 47 patients who were managed “Pre-Protocol” implementation and the 116 patients who were managed “Post-Protocol” implementation. Results: On admission, there were no significant differences in age, proportion of women, BMI, prevalence of diabetes, and Charlson score between the “Pre-Protocol” and “Post-Protocol” groups (56 vs 56 years old, 30 vs 32% women, 28 vs 29 kg/m2, 45 vs 35% with diabetes, and 2 vs 2 median Charlson scores; respectively, all p>0.05). The “Post-Protocol” group had higher proportions of patients with well-controlled glucose (i.e. 70–180 mg/dL) compared to the “Pre-Protocol” group, across all pre-meals and bedtime glucose readings throughout the hospital stay. The differences between the “Post-Protocol” and “Pre-Protocol” groups were statistically significant (p<0.05) for fasting glucose on day 4, 5, and discharge day; pre-lunch glucose on discharge day; pre-dinner glucose on day 3, 5, and discharge day; and bedtime glucose on day 1. In regression analyses adjusted for age, sex, nationality, BMI, Charlson score, and diabetes status, the odds ratios of having well-controlled glucose were significantly higher in the “Post-Protocol” group versus the “Pre-Protocol” group for fasting glucose on day 4, 5, and on discharge; pre-lunch glucose on day 5 and on discharge day; pre-dinner glucose on day 3 and 5; and bedtime glucose on day 1. Conclusion: The implementation of a simplified protocol for the management of dexamethasone-induced hyperglycemia in hospitalized patients with COVID-19 results in more patients achieving well-controlled glucose levels that have been previously associated with lower mortality of COVID-19.

Presentation of ACTH Independent Cushing’s as Severe Insulin Resistance During Pregnancy

Introduction: Cushing’s syndrome is very rare in pregnancy with around 200 cases reported in literature. It remains a diagnostic dilemma as pregnancy itself is a hypercortisolemic state. Several clinical characteristics of Cushing’s syndrome such as insulin resistance and hirsutism may overlap with normal variants of pregnancy and therefore leading to a missed diagnosis. We hereby present a case of a young pregnant woman with severe insulin resistance, with workup consistent with Cushing’s syndrome. Clinical Case: This was a 27-year-old pregnant woman with DM type 2 diagnosed about 7 years ago. During her pregnancy she was started on insulin and was later admitted to the hospital at 32 weeks for inpatient management of pre-eclampsia and uncontrolled hyperglycemia. Endocrine was consulted for severe insulin resistance and persistent hyperglycemia. On exam patient was noted to be obese with facial plethora, frontal balding and significant facial hirsutism. During the pregnancy she had noted significant weight gain with substantial worsening of frontal balding and hirsutism. Her current pregnancy was spontaneous but was after many years of trying to conceive. Prior pregnancy 8 years ago was uncomplicated with no history for GDM at that time. Review of recent pre-pregnancy imaging revealed left adrenal mass measuring 3.5 cm with 40 HU which measured around 2 cm 8 years ago. Biochemical work up revealed elevated 8 am cortisol at 35.4 ug/dL (ref range 6.2 - 19.4) with suppressed ACTH <5 pg/mL (6 – 50). Testosterone was high at 299 ng/dL (8 – 48) and DHEAS was low normal at 37 mcg/dL (18 – 391). Plasma and 24 hour urine metanephrine collection results were normal. 24-hour urine free cortisol was measured and was elevated at 628.5 mcg/24(4.0–50.0). Midnight salivary cortisol was 0.87 mcg/dL (<OR=0.09). Patient was managed conservatively with plan for surgical intervention post-delivery. Pregnancy was complicated by PPROM at 35 weeks with subsequent cesarean section. Baby was of average weight but developed mild hyperbilirubinemia which required short NICU stay. On reevaluation at 4-week postpartum period, repeat biochemical workup revealed elevated cortisol of 22.5 mcg/dL, ACTH <5 pg/ml, elevated 24-hour urine cortisol 163.9 mcg/24h with appropriate urinary creatinine. Testosterone level was improved postpartum to 9 ng/dL. DHEAS was 39 mcg/dL. Repeat imaging with CT with adrenal protocol revealed left adrenal mass measuring 2.3 cm with 20 HU with absolute washout of 79%. She was started on ketoconazole is now awaiting surgical intervention. Conclusion: We suspect that this patient may have had pregestational subclinical Cushing’s syndrome which eventually progressed to Cushing’s syndrome during pregnancy. Although this is a rare finding during pregnancy, workup for Cushing’s should be considered in pregnant women with severe insulin resistance, hirsutism, hypertension and pre-eclampsia.

Proposed Libyan Guidelines for the Management of Inpatient Hyperglycemia with Corona Virus-19 (COVID-19) Infection

Serious hyperglycemia is one of the manifestations of COVID-19 infection which increase patient morbidity and mortality especially in patient requiring hospitalization. Consequently, many protocols and algorithms for hospitalized patients with COVID-19 induced hyperglycemia based mainly on recent studies and previous evidence on non-COVID-19 patients were published. Of note nearly all guidelines released by the different COVID-19 committees in Libya don’t include a clear focus on management of in-patient hyperglycemia and maybe this plays a pivotal role in increase our COVID-19 in-hospital mortality. I proposed a simplified approach depending on the released international guidelines to be easily implemented by Libyan health care staff caring about COVID-19 patients and hoping to be accepted by our National Diabetes Committee.

In-Patient Management of Hyperglycemia during COVID-19 Pandemic

The pandemic of COVID-19 has presented new challenges to endocrine physicians and diabetologists in providing care for infected patients with dysglycemia, who may already be having diabetes and who present with newly diagnosed diabetes. The additional burden of metabolic decompensation, effect of treatment on glycemia, and the presence of comorbid complications make the management challenging. The presence of diabetes as a comorbid condition has shown to be associated with poorer outcomes in patients with COVID-19 infection. In addition, the effects of treatments such as the use of medications such as glucocorticoids and hydroxychloroquine may further add to the variability in glycemic control. Appropriate glycemic management leads to improvement in clinical outcomes, which involves intensive bedside glucose monitoring, intravenous and subcutaneous insulin administration, transition from intravenous to subcutaneous insulin, as well as interventions for hypoglycemia events. A uniform treatment protocol related to insulin administration and glucose monitoring is essential for improved clinical outcomes in admitted patients. Where feasible, continuous glucose monitoring systems have been proposed as an option for reducing time spent with patients, but they are not available everywhere and not many personnel are experienced in its usage. In-patient care of diabetes is an important issue that needs to be addressed if it is used in hospitalized patients.

Implementation of an inpatient hyperglycemia management program incorporating a nurse consultant

Background and aimsThe efficacy and safety of inpatient hyperglycemia management protocols using basal-bolus regimens have been widely demonstrated, but their implementation is insufficient. The aim of the study was to assess implementation and to establish the efficacy and safety of inpatient hyperglycemia management protocol based on a basal-bolus regimen and the incorporation of a nurse consultant. Material and methodsEvaluation was performed at 10 hospital units. Data were retrospectively reviewed during hospital stay and 90 days after discharge in 400 patients after protocol implementation and 200 patients before implementation.The degree of satisfaction of professionals was assessed using a questionnaire 12 months after implementation. ResultsThe proportion of patients with basal-bolus regimens upon admission was higher in the postimplementation group (58% vs. 9%, P < 0.001). Mean pre-prandial and bedtime blood glucose levels during admission were lower in the postimplementation group (164 ± 41 mg/L vs. 196 ± 50 mg/dL, P < 0.001). After implementation, there were less patients with blood glucose levels > 300 mg/dL (36.3% vs. 50.5%, P < 0.001) and more patients with values < 70 mg/dL (15% vs. 9%, P = 0.040). Insulin addition and intensification was the main change in treatment at discharge, and a significant HbA1c reduction was seen three months after discharge in the postimplementation phase (P = 0.04). The professionals assigned the protocol a score of 4.5 on a 1–5 scale. ConclusionsIncorporation of a nurse consultant expert in diabetes as key component of a hyperglycemia management program ensures that a majority of patients admitted to hospital for hyperglycemia receive treatment with a basal-bolus regimen and improves blood glucose control during hospital stay and after discharge.

Too Much Confidence, Too Little Knowledge

Multiple studies have shown an association between blood glucose (BG) levels and clinical outcomes in hospitalized patients ( 1. Murad M.H. Coburn J.A. Coto-Yglesias F. et al. Glycemic control in non-critically ill hospitalized patients: a systematic review and meta-analysis. J Clin Endocrinol Metab. 2012; 97: 49-58 Crossref PubMed Scopus (131) Google Scholar ). Both hyperglycemia and hypoglycemia are associated with increased mortality and morbidity ( 1. Murad M.H. Coburn J.A. Coto-Yglesias F. et al. Glycemic control in non-critically ill hospitalized patients: a systematic review and meta-analysis. J Clin Endocrinol Metab. 2012; 97: 49-58 Crossref PubMed Scopus (131) Google Scholar ). Experts from different professional organizations have suggested slightly different goals but mostly they are within a range of 80 to 200 mg/dL ( 2. American Diabetes Association 15. Diabetes care in the hospital: standards of medical care in diabetes-2019. Diabetes Care. 2019; 42: S173-S181 Crossref PubMed Scopus (155) Google Scholar ). There is consensus about preventing very high and very low BG levels. Besides professional society guidelines, glycemic control to prevent complications of hyperglycemia or hypoglycemia makes common sense. Therefore, many hospitals have set up inpatient glycemic control programs. However, despite a high emphasis on glycemic control in the hospital setting, overall glycemic control remains inadequate in most hospitals ( 5. Cook C.B. Kongable G.L. Potter D.J. Abad V.J. Leija D.E. Anderson M. Inpatient glucose control: a glycemic survey of 126 US hospitals. J Hos Med. 2009; 4: E7-E14 Crossref PubMed Scopus (142) Google Scholar , 6. Draznin B. Gilden J. Golden S.H. Inzucchi S.E. Pathways to quality inpatient management of hyperglycemia and diabetes: a call to action. Diabetes Care. 2013; 36: 1807-1814 Crossref PubMed Scopus (118) Google Scholar ). A study of data obtained from 575 hospitals in the United States revealed about 32% of the hospital patient days with at least 1 BG value above 180 mg/dL and about 6% hospital days with at least 1 BG value below 70 mg/dL ( 7. Swanson C.M. Potter D.J. Kongable G.L. Cook C.B. Update on inpatient glycemic control in hospitals in the United States. Endocr Pract. 2011; 17: 853-861 Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar ). Requests for diabetes consults are rather infrequent, even in hospitals with well-established inpatient diabetes management programs. In a recent study, only 13% of the elective surgery patients with diabetes received a diabetes consult and this number increased to 32% after implementation of a major quality improvement program ( 8. Garg R. Schuman B. Bader A. et al. Effect of preoperative diabetes management on glycemic control and clinical outcomes after elective surgery. Ann Surg. 2018; 267: 858-862 Crossref PubMed Scopus (52) Google Scholar ). The number of diabetes consults at other hospitals with less established inpatient diabetes programs are likely to be much smaller.

Implantación de un programa para el manejo de la hiperglucemia en la hospitalización con la incorporación de la enfermera consultora

Background and aimsThe efficacy and safety of inpatient hyperglycemia management protocols using basal-bolus regimens have been widely demonstrated, but their implementation is insufficient. The aim of the study was to assess implementation and to establish the efficacy and safety of inpatient hyperglycemia management protocol based on a basal-bolus regimen and the incorporation of a nurse consultant. Material and methodsEvaluation was performed at 10 hospital units. Data were retrospectively reviewed during hospital stay and 90 days after discharge in 400 patients after protocol implementation and 200 patients before implementation.The degree of satisfaction of professionals was assessed using a questionnaire 12 months after implementation. ResultsThe proportion of patients with basal-bolus regimens upon admission was higher in the postimplementation group (58% vs. 9%, P<0.001). Mean pre-prandial and bedtime blood glucose levels during admission were lower in the postimplementation group (164±41mg/L vs. 196±50mg/dL, P<0.001). After implementation, there were less patients with blood glucose levels >300mg/dL (36.3% vs. 50.5%, P<0.001) and more patients with values <70mg/dL (15% vs. 9%, P=0.040). Insulin addition and intensification was the main change in treatment at discharge, and a significant HbA1c reduction was seen three months after discharge in the postimplementation phase (P=0.04). The professionals assigned the protocol a score of 4.5 on a 1 to 5 scale. ConclusionsIncorporation of a nurse consultant expert in diabetes as key component of a hyperglycemia management program ensures that a majority of patients admitted to hospital for hyperglycemia receive treatment with a basal-bolus regimen and improves blood glucose control during hospital stay and after discharge.

1104-P: Management of Corticosteroid-Related Hospital Hyperglycemia in the “Real-World”

Guidelines recommend basal bolus insulin for inpatient hyperglycemia management based on studies performed in patients with type 2 diabetes without any corticosteroid therapy. However, in the “real-world,” corticosteroid use is common and complicates management. To better understand insulin use in corticosteroid related hyperglycemia, we conducted a large, retrospective study of patients who were: age &amp;gt;18 years, admission &amp;gt;48 hours, administered insulin &amp;gt;75% of admission, AND administered corticosteroids within the first 2 days of admission. Patients receiving IV insulin or no insulin within two days were excluded. Insulin therapy was categorized into 3 groups based on observed prescribing practices: (a) sliding scale (SS, n=481) (b) basal bolus (BB, n=356), (c) Basal plus (B+, n=386). Each group was analyzed for glucose control: days with hypoglycemia (any &amp;lt;70mg/dl), hyperglycemia (mean &amp;gt;180 mg/dl) or euglycemia (no hypo- or hyperglycemia) and clinical outcomes of length of stay (LOS), 30/60-day readmission, and hospital mortality. Patient and provider factors that influence choice of therapy were controlled using propensity score adjusted models. BB had fewer hyperglycemic days and lower LOS, albeit more hypoglycemia than SS. B+ had higher hyperglycemic and hypoglycemic days than SS. For corticosteroid related hyperglycemia, BB was a superior insulin regimen in reducing hyperglycemia and LOS. Disclosure B. Patham: None. A. Vadhariya: None. M.L. Johnson: None. S.D. Yande: None. A.R. Sadhu: None.

Manejo de pacientes diabéticos hospitalizados

La diabetes es una enfermedad con importante prevalencia en todo el mundo. Se calcula que cerca de 415 millones de personas la padecen en la actualidad y que para el año 2040 esta cifra aumentará poco más del 50%. Debido a esto, se estima que gran parte de los ingresos por urgencias serán de pacientes diabéticos o sujetos a los cuales esta patología se les diagnosticará en dicha hospitalización; esta situación hace necesario conocer los lineamientos y las recomendaciones de las guías para el manejo intrahospitalario de los pacientes con hiperglucemia.El pilar fundamental del manejo hospitalario de diabetes es la monitorización intensiva, junto con la educación al paciente y la administración de insulina. El control glicémico es clave debido a que disminuye complicaciones intrahospitalarias. Cabe resaltar que el control estricto puede llevar a hipoglucemias, por lo que los episodios deben ser debidamente documentados y su causa corregida de inmediato.

Management of Type 1 Diabetes in the Hospital Setting.

The purpose of this article was to review recent guideline recommendations on glycemic target, glucose monitoring, and therapeutic strategies, while providing practical recommendations for the management of medical and surgical patients with type 1 diabetes (T1D) admitted to critical and non-critical care settings. Studies evaluating safety and efficacy of insulin pump therapy, continuous glucose monitoring, electronic glucose management systems, and closed loop systems for the inpatient management of hyperglycemia are described. Due to the increased prevalence and life expectancy of patients with type 1 diabetes, a growing number of these patients require hospitalization every year. Inpatient diabetes management is complex and is best provided by a multidisciplinary diabetes team. In the absence of such resource, providers and health care staff must become familiar with the features of this condition to avoid complications such as severe hyperglycemia, ketoacidosis, hypoglycemia, or glycemic variability. We reviewed most recent guidelines and relevant literature in the topic to provide practical recommendations for the inpatient management of patients with T1D.