Claire Dawson
Diabetes is a condition that requires careful monitoring, especially when a patient is in hospital. The type of diabetes (e.g. type 1, type 2, gestational) should be stated, and the patient's self-management knowledge and behaviours assessed. Blood glucose monitoring is an important tool for managing diabetes, helping to identify patterns in blood glucose fluctuations in response to diet, exercise, medication, etc. Inpatient treatment and discharge planning are more effective when preadmission glycemia is considered, and so blood glucose monitoring is often performed before meals for hospitalised individuals with diabetes who are eating. For those not eating, glucose monitoring is advised every 4-6 hours.
| Characteristics | Values |
|---|---|
| Type of diabetes | Type 1, Type 2, Gestational, Pancreatogenic, Stress hyperglycemia, Drug-related, Nutrition-related |
| Diabetes self-management | Diabetes self-management education should be provided, including medication dosing, administration, glucose monitoring, and recognition and treatment of hypoglycemia |
| Blood glucose monitoring | Recommended for patients with diabetes mellitus using insulin therapy; may be performed through capillary blood glucose (CBG) tests or venous blood tests |
| Point-of-care (POC) blood glucose monitoring | Should be performed before meals for hospitalized individuals with diabetes who are eating; advised every 4-6 hours for those not eating |
| POC glucose monitoring frequency | Ranging from every 30 minutes to every 2 hours for safe use of intravenous insulin therapy |
| POC glucose monitoring devices | U.S. Food and Drug Administration (FDA)-approved POC hospital-calibrated glucose monitoring systems |
| Personal continuous glucose monitoring (CGM) devices | Use of CGM should be continued during hospitalization if clinically appropriate, with confirmatory POC glucose measurements for insulin dosing decisions and hypoglycemia assessment |
| CGM data | Data on the safety and efficacy of real-time CGM use in hospitals is growing, particularly with remote monitoring systems |
| Discharge planning | Identification of healthcare provider for diabetes care after discharge, level of understanding of diabetes diagnosis, self-monitoring of blood glucose, home blood glucose goals, and when to call the provider |
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What You'll Learn
Blood glucose monitoring
In a hospital setting, blood glucose monitoring is performed using point-of-care (POC) methods, which include capillary blood glucose (CBG) tests and venous blood tests. For hospitalized individuals with diabetes who are eating, POC blood glucose monitoring is recommended before meals. For those not eating, glucose monitoring is advised every 4-6 hours. More frequent monitoring, ranging from every 30 minutes to every 2 hours, is required for the safe use of intravenous insulin therapy.
The U.S. Food and Drug Administration (FDA) has established standards for capillary (finger-stick) POC glucose monitoring in hospitals. While POC measures generally provide adequate information, any glucose result that does not align with the patient's clinical status should be confirmed by repeating the test and, if necessary, measuring a sample in the clinical laboratory.
For individuals with diabetes who use personal continuous glucose monitoring (CGM) devices, the use of CGM should be continued during hospitalization if clinically appropriate. Confirmatory POC capillary glucose testing, using hospital-calibrated glucose meters, is recommended for insulin dosing and hypoglycemia assessment.
It is important to note that there are some differences between capillary blood glucose measurements undertaken at home and venous or arterial blood sampling done in clinical facilities. Therefore, care must be taken when interpreting results from capillary and venous tests used exclusively or in combination.
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Diabetes self-management
If self-management is to be used, a protocol should be followed, requiring agreement between the patient, nursing staff, and physician that self-management is appropriate. Patients with diabetes devices should be allowed to use them under proper supervision. For patients receiving enteral or parenteral feedings who require insulin, the regimen should cover basal, prandial, and correctional needs. It is crucial that patients with type 1 diabetes continue receiving basal insulin even if feedings are stopped.
To support self-management, hospitals should provide diabetes self-management education, including essential skills for after discharge, such as medication dosing, administration, glucose monitoring, and recognizing and treating hypoglycemia. Patients should understand the definition, recognition, treatment, and prevention of hyperglycemia and hypoglycemia. They should also be educated on making healthy food choices, using and disposing of needles and syringes, and sick-day management.
Regarding blood glucose monitoring, there are various approaches, including capillary point-of-care (POC) testing, which is convenient and widely available. However, it is important to consider overall clinical conditions that might affect the POC value, such as hemoglobin level, perfusion, and medications. Flash monitoring has been shown to be cost-effective compared to CBG self-monitoring, providing interstitial glucose measurements as frequently as every 5 minutes every hour. Nevertheless, solely monitoring interstitial fluid may not always reliably indicate rapidly changing blood glucose levels.
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Insulin therapy
The dosage of basal insulin is typically calculated based on the patient's body weight, with evidence suggesting reduced doses for patients with renal insufficiency. Insulin therapy requires careful monitoring due to its potential adverse side effect of hypoglycemia if not managed effectively. Regular daily blood glucose monitoring is recommended for patients undergoing insulin therapy to identify patterns in blood glucose fluctuations and prevent life-threatening complications.
In acute and critical care settings, pharmacists play a crucial role in adjusting patients' insulin regimens by staying informed about nutritional intake and potential procedures. This proactive approach helps prevent hypoglycemic events and addresses risk factors such as acute kidney injury, inappropriate timing of BG checks, and medication changes that impact BG levels.
The Endocrine Society guidelines recommend insulin therapy over non-insulin options for hospitalized patients. However, concerns about hypoglycemia have led professional organizations to recommend targets that minimize this risk. Intensive insulin therapy, while effective in reducing ICU and total hospital complications, has been associated with an increased risk of hypoglycemia, especially in non-critically ill patients.
To summarize, insulin therapy is a cornerstone of diabetes management in hospitals, requiring careful monitoring and adjustments to prevent adverse events like hypoglycemia. It is recommended by professional societies over non-insulin therapies for hospitalized patients, but individualization of glycemic goals is essential to balance the benefits and risks.
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Carbohydrate counting
In a hospital setting, carbohydrate counting can be offered as a practical meal-planning option for diabetic patients. Basic carbohydrate counting helps patients understand the relationship between food, physical activity, and blood glucose levels. It involves identifying carbohydrate-rich foods like starches, fruits, milk, and desserts. Patients are educated about portion control and encouraged to monitor their blood glucose levels before and after meals.
Advanced carbohydrate counting takes this a step further by incorporating pattern management and insulin-to-carbohydrate ratios. This level of carbohydrate counting is recommended for those on intensive insulin therapy, such as those with type 1 diabetes and some individuals with type 2 diabetes. It involves using an insulin-to-carbohydrate ratio to match insulin dosage to carbohydrate intake, ensuring better glycemic control.
The accuracy of carbohydrate counting is essential for effective diabetes management. Patients need education and personalized approaches to master carbohydrate estimation and adjust their insulin doses accordingly. Healthcare professionals play a vital role in empowering patients to achieve better glycemic control through individualized education and assessment.
Additionally, continuous glucose monitoring (CGM) or self-monitoring of blood glucose can complement carbohydrate counting. These monitoring techniques help patients understand how food impacts their blood sugar levels and make more informed choices. By opting for whole, unprocessed foods and limiting processed snacks, patients can better manage their blood glucose levels and overall health.
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Discharge planning
Identifying the Healthcare Provider:
It is crucial to determine the healthcare provider who will be responsible for the patient's diabetes care after discharge. This ensures continuity of care and provides a point of contact for the patient if any concerns arise.
Patient Education and Self-Management:
Educating patients about diabetes self-management is essential. This includes teaching them how to monitor their blood glucose levels, set realistic home blood glucose goals, and recognize and manage hypoglycemia and hyperglycemia. Patients should also be instructed on the proper use and disposal of needles and syringes, as well as healthy food choices. If the patient was previously managing their diabetes effectively at home, it is important to ensure that they continue to have the skills and resources to do so after discharge.
Medication Management:
Patients should understand when and how to take their diabetes medications, including insulin administration. This involves providing clear instructions on medication dosing, timing, and any necessary adjustments. It is also important to address medication adherence and ensure that patients have access to the required medications after leaving the hospital.
Follow-up Care:
Individualized Discharge Plans:
Tailoring the discharge plan to the individual needs of each patient can improve outcomes and enhance patient satisfaction. This includes considering the patient's specific circumstances, such as their home environment, social support, and access to healthcare services.
Diabetes Technology:
With the increasing use of diabetes technology, such as insulin pumps and continuous glucose monitoring systems, it is important for hospital staff to be familiar with these devices. Close collaboration with the patient's specialist diabetes team can ensure the safe and effective use of these technologies during and after hospitalization.
In conclusion, discharge planning for patients with diabetes requires a comprehensive approach that empowers patients with knowledge, skills, and ongoing support. By addressing these key considerations, healthcare providers can help patients effectively manage their diabetes after discharge and reduce the risk of complications and readmissions.
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Frequently asked questions
Diabetes monitoring in the hospital involves regular blood glucose monitoring, especially for patients with diabetes mellitus using insulin therapy. This can be done through capillary blood glucose (CBG) tests, venous blood tests, or both. Additionally, hospitals should provide diabetes self-management education, including medication dosing, administration, glucose monitoring, and recognition and treatment of hypoglycemia.
Hospitals typically use point-of-care (POC) blood glucose monitoring systems, which are US Food and Drug Administration (FDA)-approved and hospital-calibrated. For hospitalized individuals with diabetes who are eating, POC glucose monitoring is performed before meals. For those not eating, glucose monitoring is advised every 4-6 hours. More frequent monitoring, ranging from every 30 minutes to every 2 hours, is required for the safe use of intravenous insulin therapy.
It is important to assess the patient's diabetes self-management knowledge and behaviours upon admission. This includes understanding their diabetes diagnosis, self-monitoring of blood glucose, home blood glucose goals, and when to seek medical care. Additionally, patients should be provided with the necessary equipment, medications, and education at discharge, including information on healthy food choices and how to adjust their meal plans at home.
