With EndoTool Analytics , you have the ability to identify and analyze trends across the organization, track safety and clinical effectiveness, and enhance productivity. EndoTool Glucose Management. Intravenous Insulin Dosing. This was the realization Wilson Memorial Hospital, a bed hospital in western Ohio, made when it decided it needed to find a better way to control blood glucose levels across the hospital.
In , Remote Automated Laboratory System, a glycemic benchmarking service, reported that Wilson Memorial was in the lowest quartile of effective glycemic control for all benchmarked hospitals across the nation. This came after two separate attempts to make paper-based algorithms work within the organization.
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I Want To I Want to Find Research Faculty Enter the last name, specialty or keyword for your search below. A basal-bolus correctional approach long-acting insulin plus adjusted premeal short-acting insulin is the preferred strategy 24 ; however, many patients can be managed effectively using a basal insulin dose alone.
Although sliding scale insulin regimens a small amount of short-acting insulin is administered as needed based on the patient's current glucose readings are still used by some physicians, they are not recommended. A meta-analysis of eight randomized controlled trials concluded that use of a sliding scale regimen did not improve blood glucose control and was associated with an increased incidence of hyperglycemic events.
Complications of a sliding scale regimen compared with a basal-bolus approach include a higher mean daily glucose concentration 27 ; increased rate of wound infection, pneumonia, bacteremia, respiratory failure, and acute renal failure composite outcome of Frequent glycemic reassessment and dose adjustments are important components of an inpatient insulin regimen because of the variable physiologic stresses associated with acute illness.
Dosage considerations include the patient's current oral intake, comorbidities, other medications, and experience with and adherence to prior outpatient insulin therapy. The first step in prescribing inpatient insulin is to determine the total daily dose Table 3 7 , In hospitalized patients who have type 2 diabetes and renal impairment estimated glomerular filtration rate less than 45 mL per minute per 1.
Information from references 7 and In general, half of a patient's total daily dose should be given as basal or long-acting insulin typically glargine [Lantus], isophane [NPH; Humulin], or detemir [Levemir] , and the other half as bolus or pre-meal doses of a short- or intermediate-acting insulin also called nutritional insulin doses.
Bolus insulin doses are adjusted based on preprandial blood glucose measurements. These adjustments, or correctional doses, resemble sliding scale regimens but are in fact just fine-tuning adjustments to the bolus doses.
Correctional insulin is given only before meals and is intended to correct unpredictable hyperglycemia by augmenting the nutritional insulin doses. Correctional insulin can be given using a low-, intermediate-, or high-dose correction scale. A low-dose scale is appropriate if a patient's total daily dose is 20 to 42 units, whereas a moderate-dose scale is used for 43 to 84 units, and a high-dose scale is used for 85 to units.
Table 4 9 , 17 , 20 , 24 , 31 and Figure 1 4 show an overall approach to inpatient insulin regimens. Regular insulin every six hours or rapid-acting analogue insulin every four hours.
Rapid-acting analogue insulin with each meal and at bedtime reduced dose at bedtime. Metformin should not be crushed; glucagon-like peptide 1 receptor agonists should be avoided. Information from references 9 , 17 , 20 , 24 , and Information from reference 4. Once an insulin regimen has been initiated, the blood glucose response should be monitored and the dosage adjusted accordingly.
A typical monitoring strategy includes testing blood glucose before meals and at bedtime for patients who are eating. For patients who are fasting, blood glucose testing is recommended every four to six hours. Premeal blood glucose testing should be done within 30 minutes of the start of a meal, with premeal, rapid-acting insulin administered within 10 minutes before or after the start of the meal.
Diabetes planning at discharge Table 5 4 , 32 is an integral part of diabetes management and an important opportunity to address diabetes control, especially in newly diagnosed patients and those whose antihyperglycemic regimen was altered during admission. Effective communication about the outpatient diabetes regimen and medication reconciliation for the inpatient-to-outpatient transition are critical. Cross-check medications to ensure that no routine medications were stopped and that new prescriptions are safe for the patient to take.
Prescriptions for new or changed medication should be filled and reviewed with the patient and family at or before discharge. Communicate medication changes, pending tests, and follow-up needs to the primary care physician. Transmit discharge summary to the primary care physician as soon as possible after discharge.
Ensure that the patient can identify the physician who will provide outpatient diabetes care. Check the patient's level of understanding related to the diabetes diagnosis, self-monitoring of glucose levels, and blood glucose goals.
Reinforce information on nutritional habits, insulin administration, and other topics. Ensure that the patient has prescriptions for any new medications and does not have redundant prescriptions for existing home medications.
Review the role and regimen for oral diabetes medications, insulin regimens, and any other medication changes with patient. Information from references 4 and This article updates previous articles on this topic by Nau , et al.
Data Sources : Medline was searched using various combinations of terms, including inpatient, glucose, diabetes type 2, insulin, and sliding scale insulin. The search was limited to articles in English, pertaining to humans, in the years to , and from the Core Clinical Journal subset. Search dates: October 13, , and May 14, Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. School of Medicine.
Reprints are not available from the authors. Management of diabetes and hyperglycemia in hospitals [published correction appears in Diabetes Care. Diabetes Care. Glycemic control in hospitalized patients not in intensive care: beyond sliding-scale insulin.
Am Fam Physician. Outcomes and complications of diabetes mellitus on patients undergoing degenerative lumbar spine surgery. Spine Phila Pa American Diabetes Association. Standards of medical care in diabetes— Accessed May 15, Intensive insulin therapy in critically ill patients. N Engl J Med.
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