diabetes means that the body cannot produce insulin, or that it does not recognize it As an African American woman, I am intrigued by the prevalence of diabetes …
Management of the Patient with Diabetes in the Inpatient Setting This program applies to patients who have a medical history of diabetes: diabetes diagnosed and acknowledged by the treating physician This program does not apply to hospital-related hyperglycemia, attributed to medications or other factors
Major Element General Recommendations American Diabetes Association Recommendations All patients with diabetes are identified as having diabetes in the medical record Joint Commission Expectation Patients with diabetes are identified as having diabetes in the medical record, at admission and at discharge CT5 EP2 Documentation reflects the individuals: CT5 EP2 Type of diabetes if possible to determine preadmission medications for the control of diabetes including dosages
as stated by the patient weight, nutritional screening results nutrition management plan
degree of control prior to admission and severity of hyperglycemia on admission, current weight, current and anticipated nutritional status eg NPO, etc level of comprehension and competence related to diabetes selfmanagement activities
Major Element Blood Glucose Targets
American Diabetes Association Recommendations
Goals for blood glucose levels: Critically ill patients as close to 110mg/dl 61mmol/l as possible and generally 180mg/dl 100mmol/l All other patients: pre-meal blood glucose should be as close to 90130mg/dl 50-72mmol/l with a postprandial blood glucose level 180mg/dl 100mmol/l
Joint Commission Expectation
A1Cs are performed on patients for whom the results of an A1C within the last 2-3 months are not available
Preventing Hypoglycemia
Plans for treating hypoglycemia are established for each patient
An A1C is drawn at the time of admission unless the results of the patients A1C drawn within the last 60 days are known or the patient has a medical condition or has received therapy that would confound the results CT2EP2 Plans for the treatment of hypoglycemia and hyperglycemia are established for each patient DF3 EP3 A plan for coordinating administration of insulin and delivery of meals is implemented DF2 EP4 Episodes of hypoglycemia2 are identified and contributing reasons for these are captured PM1 EP2 Contributing reasons for episodes of hypoglycemia are evaluated for systemic trends eg difficulty having food trays delivered, improper ordering or timing of insulin or
antidiabetic medications, drug interactions etc PM1 EP3 Written protocols are developed for the management of patients on intravenous insulin infusions DF2 EP4
Scheduled prandial insulin doses are given in relation to meals, and adjusted to point of care glucose levels1
Episodes of hypoglycemia are documented and analyzed for trends
1
Sliding scale insulin regimens are ineffective
2
Hypoglycemia is defined as a blood sugar below 70 mg/dL ADA
Major Element Diabetes Care Providers
American Diabetes Association Recommendations
Joint Commission Expectation The following groups working with patients with diabetes have had education specific to the management of diabetes: DF1EP1 dietitians, and others involved in medical nutrition therapy, staff involved in point of care testing, medical staff, nursing staff including APNs, pharmacists, and physician assistants
A multidisciplinary program team is identified with a designated team leader PR1 EP1
Diabetes SelfManagement Education A diabetes education plan including survival skills education and followup should be developed for each patient Patients with newly diagnosed diabetes or educational deficits have at least the
following educational components reflected in the plan of care: SE3 EP4 Medication management, including how to administer insulin when appropriate and potential medication interactions Nutritional management, including the role of carbohydrate intake in blood glucose management Exercise Signs, symptoms, and treatment of hyperglycemia and hypoglycemia Treatment of hyperglycemia and hypoglycemia Importance of blood glucose
monitoring and how to obtain a blood glucose meter Instruction on use of blood glucose meter if available
Sick day guidelines Information for who to contact in case of emergency or for more information Plan for post-discharge education or self-management support Nutritional assessments are conducted for patients not consistently reaching glucose targets DF2 EP4
Medical Nutrition Therapy
Major Element Blood Glucose Monitoring
American Diabetes Association Recommendations All patients with diabetes have an order for blood glucose monitoring
Joint Commission Expectation Written blood glucose monitoring protocols for patients with known diabetes are developed and include, at a minimum, the following: DF2 EP4 measuring blood glucose upon admission a
plan for subsequent monitoring based on the patients: o type of diabetes o desired level of control o Current treatments eg use of steroids, TPN, etc o comorbidities and medical illnesses o dietary status including patients who are NPO Results of blood glucose monitoring are available to all members of the health care team CT5 EP1 The patient and the practitioner managing his or her diabetes care after discharge are informed about the patients A1C results and any unresolved issues related to glucose management CT3 EP2
Results of blood glucose monitoring are available to all members of the health care team
