All patients admitted to the hospital in noncritical care settings should have their blood glucose tested, according to a new clinical practice guideline from the Endocrine Society.

Unlike previous guidelines based largely on data from intensive care and critical care settings, the new guideline focuses on glucose management in noncritical settings, with special emphasis on systemic issues such as patient transition between hospital units and from inpatient to outpatient settings. The guidelines also include detailed guidance for creating systems and protocols to ensure optimal patient management and safety (Diabetes Care [2009;32:1119-31]).

"Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Setting: An Endocrine Society Clinical Practice Guideline" was developed by an eight-member panel with representatives from the American Diabetes Association, American Heart Association, American Association of Diabetes Educators, European Society of Endocrinology, and the Society of Hospital Medicine. The lead author was Dr. Guillermo E. Umpierrez, professor of medicine at Emory University, and chief of diabetes and endocrinology at Grady Memorial Hospital, both in Atlanta.

The guideline has eight sections, all focused on the noncritical hospital setting: diagnosis and recognition of hyperglycemia and diabetes, monitoring glycemia, glycemic targets, management of hyperglycemia, special situations, recognition and management of hypoglycemia, implementation of a glycemic control program, and patient and professional education.

The panel’s advice was characterized as "recommended" for items with strong evidence and "suggested" for items with less evidence. In the first of the guideline’s eight sections, the panel recommended all patients be assessed on admission for a history of diabetes and suggested laboratory blood glucose testing on admission for all patients, regardless of prior diagnosis of diabetes.

Dr. Richard Hellman

"There’s abundant data to show that a very large number of people … [are admitted] with undiagnosed diabetes and people also develop stress hyperglycemia" and both conditions affect patient outcomes, Dr. Richard Hellman said in an interview. Dr. Hellman is a coauthor of the guidelines and an endocrinologist who is a clinical professor of medicine at the University of Missouri–Kansas City.

<[stk -3]>While the accuracy of point-of-care testing is not optimal, the panel recommended bedside glucose testing of capillary blood because of the need to time glucose measures to the patient’s nutritional intake and medication regimens. Personal glucose meters should not be used, and continuous glucose monitors while "promising," have not been adequately tested in acute care and therefore can’t be recommended for hospital use at this time, Dr. Umpierrez and his associates wrote.<[etk]>

As in the 2009 guideline that addressed critical care patients, the glycemic targets are less than 140 mg/dL premeal and less than 180 mg/dL random for the majority of hospitalized patients with noncritical illness. Lower targets might be considered among patients who are able to achieve them without hypoglycemia, while higher targets might be appropriate for those at high risk for hypoglycemia and those with a limited life expectancy.

Medical nutrition therapy is recommended as a component of the glycemic management program for all hospitalized patients with diabetes and hyperglycemia. Meals with consistent amounts of carbohydrate are suggested to help coordinate dosing of rapid-acting insulin.

01/09/12