Hospitalized Patients With High Blood Glucose

New Guidelines Address Treatment of Hospitalized Patients With High Blood Glucose Levels CME/CE

News Author: Laurie Barclay, MD
CME Author: Charles Vega, MD, FAAFP

CME/CE Released: 05/11/2009; Valid for credit through 05/11/2010

May 11, 2009 — A consensus statement of the American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA) issues clinical recommendations on the proper treatment of hospitalized patients with high blood glucose levels.

The new guidelines, which target healthcare professionals, supporting staff, hospital administrators, and others involved in improved management of hyperglycemia in inpatient settings, are published in the May/June issue of Endocrine Practice and in the May issue of Diabetes Care.

"Although the costs of illness-related stress hyperglycemia are not known, they are likely to be considerable in light of the poor prognosis of such patients," write Etie S. Moghissi, MD, FACP, FACE, from the University of California in Los Angeles, and colleagues. "There is substantial observational evidence linking hyperglycemia in hospitalized patients (with or without diabetes) to poor outcomes. Cohort studies as well as a few early randomized controlled trials (RCTs) suggested that intensive treatment of hyperglycemia improved hospital outcomes."

In 2004, the American College of Endocrinology (ACE) and the AACE, in collaboration with the ADA and other medical organizations, developed recommendations for treatment of inpatient hyperglycemia. These guidelines generally endorsed tight glycemic control in critical care units. In 2005, the ADA annual Standards of Medical Care included recommendations for treatment of inpatient hyperglycemia. In 2006, the ACE and ADA collaborated on a joint "Call to Action" for inpatient glycemic control, highlighting several barriers to systematic implementation in hospitals.

Questions to Be Considered

The main objectives of the AACE and ADA in preparing this updated consensus statement were to identify reasonable, achievable, and safe glycemic targets and to describe the protocols, procedures, and system improvements needed to facilitate their implementation. After extensive review of the most current literature, members of the consensus panel considered the following questions:

1. Does improving glycemic control for inpatients with hyperglycemia improve clinical outcomes?

2. What glycemic targets should be recommended for different patient populations?

3. In specific clinical situations, which available treatment options can safely and effectively achieve optimal glycemic targets?

4. What safety issues are associated with inpatient management of hyperglycemia?

5. What systems need to be in place to implement these recommendations?

6. Is it cost-effective to treat hyperglycemia in hospitalized patients?

7. What are the best strategies to shift management of hyperglycemia to outpatient care?

8. What additional research is needed?

Recommendations for Critically Ill Patients

Specific clinical recommendations for critically ill patients are as follows:

• For treatment of persistent hyperglycemia, beginning at a threshold of no greater than 180 mg/dL (10.0 mmol/L), insulin therapy should be started.

• For most critically ill patients, a glucose range of 140 to 180 mg/dL (7.8 - 10.0 mmol/L) is recommended once insulin therapy has been started.

• To achieve and maintain glycemic control in critically ill patients, the preferred method is intravenous insulin infusions.

• Validated insulin infusion protocols that are shown to be safe and effective and to have low rates of hypoglycemia are recommended.

• To reduce hypoglycemia and to achieve optimal glucose control, frequent glucose monitoring is essential in patients receiving intravenous insulin.

Recommendations for Patients Who Are Not Critically Ill

Specific clinical recommendations for noncritically ill patients are as follows:

• For most noncritically ill patients receiving insulin therapy, the premeal blood glucose target should generally be less than 140 mg/dL (< 7.8 mmol/L), and random blood glucose levels should be less than 180 mg/dL (< 10.0 mmol/L), provided these targets can be safely achieved.

• In stable patients in whom tight glycemic control was previously achieved, more rigorous targets may be appropriate.

• In terminally ill patients or in those with severe comorbidities, less stringent targets may be appropriate.

• For achieving and maintaining glucose control, the preferred method is scheduled subcutaneous administration of insulin, with basal, nutritional, and correction components.

• Prolonged treatment with sliding-scale insulin as the only therapeutic agent is discouraged.

• For most hospitalized patients who require treatment of hyperglycemia, noninsulin antihyperglycemic agents are not appropriate.

• Day-to-day decisions concerning treatment of hyperglycemia must be based on clinical judgment and ongoing evaluation of clinical status.

Safety Recommendations

Specific recommendations geared toward improving safety in management of inpatient hyperglycemia are as follows:

• Major safety issues include overtreatment and undertreatment of hyperglycemia.

• Hospital staff must be educated to engage the support of those involved in the care of inpatients with hyperglycemia.

• In patients with anemia, polycythemia, hypoperfusion, or use of some medications, caution is needed when interpreting results of point-of-care glucose meters.

• To promote a rational systems approach to inpatient glycemic management, buy-in and financial support from hospital administration are required.

The guidelines also propose a selected number of research questions and topics to guide the management of inpatient hyperglycemia in different hospital settings.

"Appropriate inpatient management of hyperglycemia is cost-effective," the guidelines authors conclude. "Preparation for transition to the outpatient setting should begin at the time of hospital admission. Discharge planning, patient education, and clear communication with outpatient providers are critical for ensuring a safe and successful transition to outpatient glycemic management."

Some of the guidelines authors have disclosed various financial relationships with sanofi-aventis U.S. LLC; Amylin Pharmaceuticals, Inc;Takeda Pharmaceuticals North America, Inc; AstraZeneca; GlaxoSmithKline; Johnson & Johnson Services, Inc; Eli Lilly & Co; Medtronic, Inc; Novo Nordisk A/S; Halozyme Therapeutics; MannKind Corporation; Abbott Laboratories; F. Hoffman La Roche Ltd. (Roche); and/or Merck & Co.

Endocr Pract. 2009;15:1-15.

Diabetes Care. Published online May 8, 2009.
Clinical Context

Hyperglycemia is common in the inpatient setting, and reducing high blood glucose levels is associated with better patient outcomes. However, a study by Finfer and colleagues, which was published in the March 26, 2009, issue of The New England Journal of Medicine, found that more intense glucose treatment could actually result in higher mortality rates in critically ill patients.

Compared with a cohort of patients randomly assigned to a target blood glucose level of 180 mg/dL or less, participants randomly selected to target glucose levels of 81 to 108 mg/dL experienced a 14% increase in the risk for death. Rates of hypoglycemia were much higher in the intensive vs standard-control group, and intensive therapy did not significantly alter the duration of hospital stay, the need for renal replacement therapy, or the number of days of mechanical ventilation.

The current review examines the sum of evidence for the management of hyperglycemia in inpatient settings and makes treatment recommendations.
Study Highlights

* Treatment of hyperglycemia is associated with reduced rates of wound infection after cardiothoracic surgery, lower rates of infection and lower poor neurologic outcomes in patients with traumatic brain injury, and reduced rates of congestive heart failure after acute myocardial infarction.
* The current recommendations state that hyperglycemia be treated at a threshold of 180 mg/dL in critically ill patients. The target glucose level should be between 140 and 180 mg/dL.
* Intravenous insulin infusion is the preferred means of treatment of hyperglycemia in critically ill patients.
* There is less clinical evidence regarding the treatment of hyperglycemia in hospitalized patients who are not critically ill, so the current recommendations regarding this subject are based on clinical experience and judgment. The authors suggest that premeal glucose targets should be less than 140 mg/dL, and random blood glucose values should be less than 180 mg/dL.
* Less stringent treatment criteria may be appropriate for terminally ill patients and those with severe comorbidities.
* To avoid hypoglycemia in patients without critical illness, clinicians should consider altering the insulin regimen if blood glucose levels decline below 100 mg/dL.
* The ideal treatment of hyperglycemia in noncritically ill hospitalized patients should involve basal, nutritional, and correction insulin delivered subcutaneously.
* Treatment with sliding-scale insulin therapy alone is discouraged, and noninsulin antihyperglycemic agents do not have a significant role among inpatients.
* Hyperglycemia develops in many patients receiving corticosteroids. These patients should receive at least 48 hours of blood glucose monitoring and treatment as appropriate.
* In patients receiving continuous enteral or parenteral nutrition, blood glucose monitoring should be performed every 4 to 6 hours. Glucose testing should be performed every 30 minutes to 2 hours in patients receiving intravenous insulin infusions.
* Appropriate inpatient management of hyperglycemia is cost-effective.
* Multidisciplinary teams can establish and enforce local hospital recommendations regarding inpatient treatment of hyperglycemia, and preprinted order sets and computerized ordering systems can improve guideline adherence.

Clinical Implications

* A recent study found a higher risk for death associated with more intensive treatment of hyperglycemia in critically ill patients.
* The current recommendations suggest that antihyperglycemic treatment should begin when the blood glucose level reaches 180 mg/dL among critically ill inpatients, and blood glucose levels should be maintained between 140 and 180 mg/dL in these patients. Blood glucose levels should be maintained below 140 mg/dL before meals and below 180 mg/dL at random times among other inpatients.

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mayo never

Dec. 4--Mayo Clinic has again reported deaths related to medical "never events," events health experts believe should "never" occur in the health-care environment.

Each year, up to 98,000 Americans die from medical errors, according to the 1999 Institute of Medicine report called "To Err is Human: Building a Safer Health System."

In 2003, the Minnesota Adverse Health Care Events Act was passed at the urging of hospitals. It requires reporting of never events once each year. The state's goal is to alert hospitals whenever errors are recognized as potentially repeatable.

Increasing attention nationwide has led to increased public disclosure. St. Cloud Hospital, for example, reports blood-infection rates and prices for its most-common treatments.

Mayo Clinic began in May of 2007 to share medical-error summaries with its 31,000-plus Rochester employees four times yearly, rather than the annually as required.

In the 2008 fourth quarter employee newsletter, Mayo reported that during the fourth-quarter reporting period:

--Two patients died after preventable falls. Both experienced brain bleeding before death.

--Two patients were disabled by falls. One received a "two-part" shoulder fracture. The other "sustained a ruptured eye globe." Both required surgery.

"The Mayo Fall Prevention Subcommittee is actively involved in identifying interventions that will minimize harm from falls," the clinic noted.

--Two patients had serious disability associated with medication errors. One still had a "neurological deficit" at discharge.

New protocols and better chemotherapy prescribing supervision were begun. The other patient got inadequate anticoagulation, yielding paralysis on one side of the body.

--Three patients had items still in them after surgery. One had an object in the eye after retinal reattachment surgery.

"The object eventually migrated to the eyelid and was removed," Mayo reported in the employee newsletter. A sponge was retained in another patient, and a guide wire came out of a central venous catheter and had to be removed from a third.

Staff will get hands-on training about the catheters, the clinic reported. Post-surgery item counts are also being emphasized.

--Five patients got pressure ulcers during prolonged hospitalizations. A prevention team was set up.

To put the errors in context, Mayo reported in March that it treated 520,000 patients in 2007.

For more information, visit Postbulletin.com/weblinks.

St. Cloud Hospital, click on "Quality, Safety & Pricing": http://www.centracare.com/hospitals/sch/index.html

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