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CopyrightAll rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means without the written prior permission of the International Diabetes Federation (IDF). Requests to reproduce or translate IDF publications should be addressed to IDF Communications, Avenue Emile de Mot 19, B-1000 Brussels,by fax at +32-2-5385114, or by e-mail at [email protected] International Diabetes Federation, 2005 HO1 Designate a diabetes-trained health-care professional to: ß manage and co-ordinate systems of care related to diabetes management co-ordinate training of hospital staff in awareness of the needs of people with diabetes ß implement strategies to prevent disempowerment of those who could ß plan for discharge and follow-up.
HO2 Provide access for people with diabetes and hospital staff to a multidisciplinary HO3 Ensure laboratory/service support for: ß assays including plasma glucose, HbA , basic haematology and biochemistry, lipid profi le and hormone assays HO4 Encourage self-management of diabetes (food choice, self-monitoring, insulin dose adjustment where appropriate) integrated into usual ward care.
Management during in-patient procedures HO5 Evaluate blood glucose control, and metabolic and vascular complications (in particular renal and cardiac status) prior to planned procedures; provide advice on the management of diabetes on the day or days prior to the procedure. HO6 Ensure the provision and use of an agreed protocol for in-patient procedures HO7 Aim to maintain near-normoglycaemia without hypoglycaemia by regular quality-assured blood glucose testing and intravenous insulin delivery where needed, generally using a glucose/insulin/potassium infusion.
HO8 Ensure awareness of special risks to people with diabetes during hospital ß neuropathy (heel ulceration, cardiac arrest) i ntra-ocular bleeding from new vessels (vascular and other surgery requiring drug therapy (risks of acute renal failure causing lactic acidosis in people on metformin, for example with radiological contrast media).
HO9 Provide access to intensive care units (ICU) for life-threatening illness, ensuring that strict blood glucose control, usually with intravenous insulin therapy, is a routine part of system support for anyone with hyperglycaemia. HO10 Provide protocol-driven care to ensure detection and immediate control of hyperglycaemia for anyone with a presumed acute coronary event or stroke, normally using intravenous insulin therapy with transfer to subcutaneous insulin therapy once stable and eating.
n Comprehensive careHO 1 General principles are as for Standard care, but would include repeated review by a diabetes specialist where general health state is changing or glucose control is problematic.
HO 2 Use telematic review of blood glucose control to a specialist’s offi ce for people in HO 3 Maintain staff trained in aspects of diabetes management on any ward or procedure area with a signifi cant throughput of people with diabetes.
n Minimal careHO 1 General principles are as for Standard care, but hospitals should designate an individual in charge of matters relating to in-patient diabetes, to co-ordinate training in awareness of the needs of, and provision of in-patient care to, people with diabetes, and the provision and use of guidelines and protocols. HO 2 Laboratory assays should include plasma glucose and basic biochemistry; basic HO 3 Management of plasma glucose levels during in-patient procedures will generally be as for Standard care. Where this is impossible or carries special risk, frequent intramuscular insulin with frequent monitoring may be useful in emergency situations, or frequently monitored subcutaneous insulin therapy (e.g. with NPH insulin) for minor procedures or more stable health states.
prompt glucose control). For SC insulin they discourage the use of sliding scales. They found some evidence for a Hyperglycaemia is found, and requires management, in diabetes team approach (reduced length of stay, fewer re- hospital settings not only in people with known diabetes but also in people with previously unrecognized diabetes and in people with hospital-related hyperglycaemia which The Canadian guidelines also make recommendations on reverts to normal after discharge. Prevalence of diabetes in blood glucose levels, emphasizing tight control (4.5-6.0 hospitalized adult patients is 12-25 % or more [1]. Hospital mmol/l, 80-110 mg/dl) for post-operative ICU patients if care for people with diabetes may be required for metabolic random plasma glucose >6.1 mmol/l (>110 mg/dl) [4]. They emergencies, in-patient stabilization of diabetes, diabetes- found strong evidence for recommending that all patients related complications, intercurrent illnesses, surgical with acute MI and blood glucose >12.0 mmol/l (>215 mg/dl) procedures, and labour and delivery (see Pregnancy should receive insulin-glucose infusion therapy to maintain blood glucose between 7.0 and 10.0 mmol/l (125-180 mg/dl) for at least 24 h, followed by multi-dose SC insulin for at least 3 months.
Recent growth in the literature on hospital hyperglycaemia is refl ected in the inclusion of sections on in-patient Neither ACE nor the Canadian guideline addresses the issue management in diabetes guidelines. The 2005 ADA of oral glucose-lowering drugs in the hospital setting, but standards have added a section on diabetes care in the the ADA [1] draws attention to limitations for in-patient use hospital [1], drawing on a technical review [2] and the (especially with regard to fl exibility) of the major classes. For position statement of the American College of Endocrinology metformin, the fact that many specifi c contra-indications (ACE) [3]. The Canadian guidelines include separate sections (related to risks of renal impairment) to its use are found on peri-operative and peri-acute coronary syndrome in the hospital setting was seen as limiting its use. For glycaemic control [4]. NICE reviewed evidence from people thiazolidinediones haemodynamic changes were felt to be with Type 2 diabetes when developing recommendations for an issue, and for sulfonylureas risk of hypoglycaemia.
in-patient care in Type 1 diabetes [5].
One cost study, cited by ACE, found cost per QALY for The recent ACE position statement was based on a review intravenous insulin therapy in patients with acute myocardial of the literature on in-hospital hyperglycaemia [3]. They infarction to be comparable to that for other well-accepted found multiple studies confi rming that hospitalized patients with hyperglycaemia suffer signifi cant excess mortality and morbidity, prolonged length of stay, unfavourable post- NICE additionally notes the utility and importance of a discharge outcomes, and signifi cant excess health-care holistic approach, using the skills and knowledge of a person costs. They found RCTs as well as prospective observational with diabetes developed over years or decades [5].
and retrospective studies demonstrating improved outcomes (mortality, infection, intubation time, length of hospital stay) resulting from more aggressive treatment of hyperglycaemia. They strongly support the need for It was considered important that hospitals should designate early detection of hyperglycaemia in the hospital and an a ‘diabetes lead’ individual, who would be in charge of aggressive management approach to improve outcomes. matters relating to diabetes, and could co-ordinate training of staff in awareness of the needs of those with diabetes, ACE propose upper limits for blood glucose targets and develop strategies to prevent disempowerment (ICU 6.1 mmol/l (110 mg/dl); non-ICU 6.1 mmol/l pre- of those who could self-manage their diabetes. Major prandial, 10.0 mmol/l (180 mg/dl) maximum), with the considerations were that diabetes should not complicate proviso that those for non-intensive care patients are the management of whatever condition resulted in less well supported by the evidence. They list indications admission to hospital, and that a person’s diabetes for intravenous insulin infusion therapy (critical illness, should not emerge from hospital worse than when they prolonged nil-by-mouth status in insulin-defi cient patients, were admitted. While the evidence over use of protocol- peri-operative period, post transplantation, total parenteral driven intravenous insulin regimens is not conclusive, nutrition therapy, elevated glucose exacerbated by high- the widespread and general adoption of these regimens dose glucocorticoid therapy, stroke, dose-fi nding prior to globally appears telling (for more detail of methods see subcutaneous (SC) insulin injections, other illnesses requiring 7. European Diabetes Policy Group 1999. A desktop guide to Type 2 diabetes: management of diabetes during Systems of care and protocols need to be put in place and surgery. Diabet Med 1999; 16: 729-30. http://www.staff.
staff trained to ensure their effectiveness. Standardized protocols, developed by multidisciplinary teams, should specify insulin dose, include guidelines for identifying patients at risk for hypoglycaemia, and actions to be taken to prevent and treat hypoglycaemia. Bedside glucose monitoring requires defi ned administrative responsibility, a procedure manual, training, policies regarding frequency (hourly to twice-daily) and procedures for alert values, quality control, and regular maintenance of equipment.
EvaluationEvaluation should consider evidence of the availability of trained staff (and training courses) and of protocols as above. Audit can be made of ward blood glucose control, and blood glucose control during surgery, after myocardial infarction and in intensive care. Admissions to coronary care can be reviewed to ensure measurement of blood glucose is occurring, and appropriate actions are then taken while in the unit and during follow-up.
1. American Diabetes Association Position Statement. Standards of Medical Care in Diabetes. Diabetes Care 2005; 28 (Suppl 1): S4-S36.
2. Clement S, Braithwaite SS, Magee MF, Ahmann A, Smith EP, Schafer RG, et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care 2004; 27: 553-97.
3. Garber AJ, Moghissi ES, Bransome ED Jr, Clark NG, Clement S, Cobin RH, et al. American College of Endocrinology position statement on inpatient diabetes and metabolic control. Endocr Pract 2004; 10: 77-82.
4. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2003 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Canadian Journal of Diabetes 2003; 27(Suppl 2): S113-S116. http://www.diabetes.ca 5. The National Collaborating Centre for Chronic Conditions. Type 1 Diabetes in Adults. National clinical guideline for diagnosis and management in primary and secondary care. http://www.rcplondon.ac.uk/pubs/books/DIA/index.asp 6. Gill GV, Alberti KGMM. The care of the diabetic patient during surgery. In: DeFronzo RA, Ferrannini E, Keen H, Zimmet P (eds) International Textbook of Diabetes Mellitus, 3rd edn. Chichester: Wiley, 2004: pp 1741-51.

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