2018 Clinical Practice Guidelines

In-Hospital Management of
Diabetes
Chapter 16
Janine Malcolm MD FRCPC, Ilana Halperin MD FRCPC, David
Miller MD FRCPC, Sarah Moore RN(EC) BScN MN, Kara
Nerenberg MD FRCPC, Vincent Woo MD FRCPC, Catherine Yu
MD FRCPC
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2018 Diabetes Canada CPG – Chapter 16. In-hospital Management of Diabetes

2018
Key Changes
• New recommendations for:
• screening hospitalized patients with newly diagnosed
hyperglycemia, diabetes risk factors, or pre-existing
diabetes with A1C
• frequency and timing of bedside CBG monitoring
• use of IV insulin infusion for perioperative management
of patients undergoing CABG to prevent surgical site
infections
• post-operative protocols using basal/bolus therapy in
patients with diabetes requiring insulin therapy
• New glycemic targets for various categories of in-
hospital people with diabetes

CBG, capillary blood glucose monitoring; IV, intravenous

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2018 Diabetes Canada CPG – Chapter 16. In-hospital Management of Diabetes

In-hospital Management
Checklist
CHECK A1C if it has not been done in the last 3 months
CONTINUE pre-hospital diabetes regimen if appropriate,
otherwise …
USE insulin as the treatment of choice
DO NOT use sliding scale insulin alone
DO use BASAL + BOLUS + CORRECTION insulin
regimen
AVOID hypoglycemia

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2018 Diabetes Canada CPG – Chapter 16. In-hospital Management of Diabetes

In-hospital Hyperglycemia is
Common
• Approximately 1/3 of
in-patients have been
found to have
Hyperglycemia
hyperglycemia

• Many have pre-

existing diabetes prior
to admission

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2018 Diabetes Canada CPG – Chapter 16. In-hospital Management of Diabetes

Hyperglycemia and Acute Ilness

Hyperglycemia

Increased stress Decreased

hormones, use of immune
glucocorticoids, function, wound
decreased level of healing,
activity increased
oxidative stress

Acute Illness

Inzucchi SE. NEJM 2006;355;1903

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2018 Diabetes Canada CPG – Chapter 16. In-hospital Management of Diabetes

Adverse Effects of Hyperglycemia

Hyperglycemia

Increases risks Prolonged Increased renal

of postoperative hospital stay, dysfunction and
infections and resource renal allograft
delirium utilization rejection in
transplant

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Screen for diabetes in hospital
with A1C
• Patients with newly diagnosed hyperglycemia or
diabetes risk factors can be screened with A1C if
not done in 3 months prior to admission to identify
patients at risk of ongoing hyperglycemia

• A1C may be measured on people with pre-existing

diabetes if not done in prior 3 months to identify
those requiring glycemic optimization

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Recommended frequency of
CBG monitoring
Clinical Scenario Monitoring Frequency and Timing

People who are eating Before meals and bedtime

NPO Every 4 to 6 hours

Continuous Enteral Feeds Every 4 to 6 hours

IV fluids Every 1 to 2 hours

Critically Ill Every 1 to 2 hours

*Frequency and timing of monitoring should be individualized

CBG, capillary blood glucose monitoring

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2018 Diabetes Canada CPG – Chapter 16. In-hospital Management of Diabetes

Recommended glycemic targets for

hospitalized people with diabetes
Hospitalized population Blood glucose targets
with diabetes (mmol/L)
Non-critically ill preprandial: 5.0 - 8.0
random: <10.0
Critically ill 6.0 - 10.0
CABG intraoperatively 5.5 - 11.1
Perioperatively for other 5.0 - 10.0
surgeries
Acute coronary syndrome 7.0 - 10.0
Labour and delivery 4.0 - 7.0

Less stringent targets may be appropriate in terminally ill patients or in people with severe
comorbidities
CABG, coronary artery bypass grafting PERSONAL USE ONLY
2018 Diabetes Canada CPG – Chapter 16. In-hospital Management of Diabetes

Sliding Scale Alone is Inefficient

BG (mmol/L) Bolus insulin (U) In the absence of routine
<4 Call MD insulin, sliding scale insulin
4.1 – 10.0 0 regimen (bolus insulin on a prn
10.1 – 13.0 2 basis) is purely reactive rather
than proactive and allows for
13.1 – 16.0 4
hyperglycemia to occur before
16.1 – 19.0 6
responding
>19.0 Call MD

Queale WS. et al. Arch Int Med 1997;157

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2018 Diabetes Canada CPG – Chapter 16. In-hospital Management of Diabetes

Sliding Scale Insulin Alone Results in

Variable Glucose Control
BG (mmol/L) 16.5 What do you do?
What do you do?
+6 U
14.0 +4 U
Sliding Scale alone
BG (mmol/L) Bolus insulin
(U)
10.0
<4 Call MD
4.1 – 10.0 0
10.1 – 13.0 2
13.1 – 16.0 4
6.0 6.0 16.1 – 19.0 6
4.0 What do you do? What do you do?
> 19.0 Call MD
0U 0U
3.0
Breakfast Lunch Dinner Bedtime
Bolus insulin QID

QID,four times daily; SSI, sliding-scale insulin; BG, blood glucose

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2018 Diabetes Canada CPG – Chapter 16. In-hospital Management of Diabetes

Use BASAL + BOLUS +

CORRECTION
BOLUS + CORRECTION In-hospital circumstances
may warrant temporarily
holding other
antihyperglycemic
Insulin

medications (e.g. renal or

hepatic impairment)

Insulin = treatment of choice

BASAL
Breakfast Lunch Dinner BASAL + BOLUS +
CORRECTION

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2018 Diabetes Canada CPG – Chapter 16. In-hospital Management of Diabetes

BASAL + BOLUS + CORRECTION Results in

Smoother Glycemic Control
6+2 U
What do you do?
Correctional Insulin AC meals
12.0 BG (mmol/L) Bolus insulin
(U)
10.0 <4 Call MD
6+0 U
What do
What do 4.1 – 10.0 0
you do?
you do? 10.1 – 13.0 2

6.0 6.0 6.0 13.1 – 16.0 4

4.0 What do you do? 18 U 16.1 – 19.0 6
6+0 U
> 19.0 Call MD
Breakfast Lunch Dinner Bedtime

6U 6U 6U Basal
insulin
ROUTINE Bolus insulin Routine Basal
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2018 Diabetes Canada CPG – Chapter 16. In-hospital Management of Diabetes

Basal-Bolus (BBI) Regimen Achieves Better

Control than Sliding Scale (SSI) Alone
RABBIT 2 RABBIT 2 Surgery
13.3 13.3
*
Blood glucose (mmol/L)

12.2
11.1
*
11.1 *
* SSI * SSI
¶
¶
10.0
¶ 10.0
¶ ŧ
ŧ †
8.9 8.9 †

7.8
7.8
6.7
*p < 0.01; ¶p < 0.05. BBI *p < 0.001, ŧp = 0.02, †p = 0.01 BBI
5.6 6.7
Admit 1 2 3 4 5 6 7 8 9 10 Randomi 1 2 3 4 5 6 7 8 9
-zation
Duration of treatment (days) Duration of treatment (days)

Adapted from: Umpierrez GE, et al. Diabetes Care 2007;30:2181-86.

Adapted from: Umpierrez GE, et al. Diabetes Care 2011;34:256-61.
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2018 Diabetes Canada CPG – Chapter 16. In-hospital Management of Diabetes

IV Insulin protocols reduce surgical site

infections in patients undergoing CABG

Boreland L, et al. Heart & Lung 2015; 44:430-440

CABG, coronary artery bypass grafting
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2018 Diabetes Canada CPG – Chapter 16. In-hospital Management of Diabetes

Avoid Hypoglycemia
• Protocols for hypoglycemia avoidance, recognition and
management should be implemented with nursing-
initiated treatment
• Patients at risk of hypoglycemia should have ready
access to an appropriate source of glucose at all times
• Insulin protocols and order sets may be used to
improve adherence to optimal insulin use and
glycemic control

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2018 Diabetes Canada CPG – Chapter 16. In-hospital Management of Diabetes

Organization of Care
• Institution wide programs with the following
elements can result in improvements in in-hospital
glycemic control:
• Inter-professional team based care
• Health-care professional development focused
on in-hospital diabetes management
• Algorithms, order sets and decision support
• Comprehensive quality assurance initiatives

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2018 Diabetes Canada CPG – Chapter 16. In-hospital Management of Diabetes

2018
Recommendation 1
1. An A1C should be measured if not done in the 3 months prior
to admission on:
• All hospitalized people with a history of diabetes to identify
individuals that would benefit from glycemic optimization
[Grade D, Consensus]
• All hospitalized people with newly diagnosed
hyperglycemia or those with diabetes risk factors to
identify individuals at risk for ongoing dysglycemia [Grade C,
Level 3]
• Repeat screening should be performed 6 to 8 weeks post
hospital discharge for individuals with an A1C 6.0%-6.4%
[Grade D, Consensus]
• In-hospital CBG monitoring should be initiated for
individuals with an A1C ≥6.5% [Grade D, Consensus]

CBG, capillary blood glucose monitoring

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2018 Diabetes Canada CPG – Chapter 16. In-hospital Management of Diabetes

2018
Recommendation 2
2. The frequency and timing of bedside CBG
monitoring should be individualized for all in-
hospital people with diabetes. Monitoring should
typically be performed:
• Before meals and at bedtime in people who are
eating [Grade D, Consensus]
• Every 4 to 6 hours in people who are NPO or
receiving continuous enteral feeding [Grade D,
Consensus]
• Every 1 to 2 hours for people on continuous
intravenous insulin or those who are critically ill
[Grade D, Consensus]

CBG, capillary blood glucose monitoring

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2018 Diabetes Canada CPG – Chapter 16. In-hospital Management of Diabetes

Recommendation 3
3. Provided that their medical conditions, dietary intake
and glycemic control are stable, people with diabetes
should be maintained on their pre-hospitalization
non-insulin antihyperglycemic agents or insulin
regimens [Grade D, Consensus]

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2018 Diabetes Canada CPG – Chapter 16. In-hospital Management of Diabetes

Recommendation 4
4. For hospitalized people with diabetes treated with
insulin, a proactive approach that includes basal,
bolus and correction (supplemental) insulin,
along with pattern management, should be used to
reduce adverse events and improve glycemic control,
instead of only correcting high BG with short- or
rapid-acting insulin [Grade A, Level 1A]

BG, blood glucose

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2018 Diabetes Canada CPG – Chapter 16. In-hospital Management of Diabetes

Recommendation 5
5. For the majority of non-critically ill hospitalized
people with diabetes, preprandial BG targets should
be 5.0 to 8.0 mmol/L in conjunction with random BG
values <10.0 mmol/L, as long as these targets can
be safely achieved [Grade D, Consensus]

BG, blood glucose

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2018 Diabetes Canada CPG – Chapter 16. In-hospital Management of Diabetes

Recommendation 6
6. For most medical/surgical critically ill hospitalized
people with diabetes with hyperglycemia, a
continuous intravenous insulin infusion should be
used to maintain BG <10.0 mmol/L [Grade B, Level 2]
and >6.0 mmol/L [Grade D, Consensus]

BG, blood glucose

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2018 Diabetes Canada CPG – Chapter 16. In-hospital Management of Diabetes

2018
Recommendation 7
7. For people with diabetes undergoing CABG, a
continuous IV insulin infusion protocol targeting
intraoperative glycemic levels between 5.5 and 11.1
mmol/L should be used, rather than subcutaneous
insulin, to prevent postoperative infections [Grade A,
Level 1A]

CABG, coronary artery bypass grafting

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2018 Diabetes Canada CPG – Chapter 16. In-hospital Management of Diabetes

2018
Recommendation 8
8. In hospitalized people with diabetes requiring insulin
therapy, protocols using basal insulin with/without
bolus insulin should be used for postoperative
glycemic management [Grade B, Level 2]

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2018 Diabetes Canada CPG – Chapter 16. In-hospital Management of Diabetes

Recommendation 9
9. In hospitalized people with diabetes, hypoglycemia
should be minimized. Protocols for hypoglycemia
avoidance, recognition and management should be
implemented with nurse-initiated treatment,
including glucagon for severe hypoglycemia when
intravenous access is not readily available [Grade D,
Consensus]. Hospitalized people with diabetes at risk
of hypoglycemia should have ready access to an
appropriate source of glucose (oral or IV) at all times,
particularly when NPO or during diagnostic
procedures [Grade D, Consensus]

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2018 Diabetes Canada CPG – Chapter 16. In-hospital Management of Diabetes

2018
Recommendation 10
10. Programs consisting of the following elements should
be implemented for optimal inpatient diabetes care:
• Interprofessional team-based approach [Grade B, Level 2]
• Health-care professional development regarding in-
hospital diabetes management [Grade D, Level 4]
• Algorithms, order sets and decision support [Grade C, Level
3]
• Comprehensive quality assurance initiatives including
institution-wide BG monitoring systems, inpatient education,
and transition/continuity of care and discharge planning
[Grade D, Consensus]

BG, blood glucose

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2018 Diabetes Canada CPG – Chapter 16. In-hospital Management of Diabetes

Key Messages
• Hyperglycemia is common in hospitalized people,
even among those without a previous history of
diabetes, and is associated with increased in-hospital
complications, longer length of stay, and mortality

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2018 Diabetes Canada CPG – Chapter 16. In-hospital Management of Diabetes

Key Messages
• Insulin is the most appropriate pharmacologic agent
for effectively controlling glycemia in hospital.

• A proactive approach to glycemic management using

scheduled basal, bolus and correction
(supplemental) insulin is the preferred method.

• The use of correction (supplemental) only insulin,

which treats hyperglycemia only after it has occurred,
should be discouraged as the sole modality for
treating elevated blood glucose levels.

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2018 Diabetes Canada CPG – Chapter 16. In-hospital Management of Diabetes

Key Messages
• Glycemic targets for the majority of non-critically ill
hospitalized people with diabetes are:
• preprandial 5.0 to 8.0 mmol/L, in conjunction with
random BG <10.0 mmol/L, as long as these targets
can be safely achieved.

• For critically ill hospitalized people with diabetes, BG

levels should be maintained between 6.0 and 10.0
mmol/L

BG, blood glucose

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2018 Diabetes Canada CPG – Chapter 16. In-hospital Management of Diabetes

Key Messages
• Hypoglycemia is a major barrier to achieving targeted
glycemic control in the hospital setting.
• Health-care institutions should develop protocols for
the assessment and treatment of hypoglycemia

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2018 Diabetes Canada CPG – Chapter 16. In-hospital Management of Diabetes

Key Messages for People with

Diabetes
• If your admission to hospital is planned, talk with your
healthcare providers in order to develop an in-hospital
diabetes care plan that addresses issues:
• who will manage your diabetes in the hospital;
• will you be able to self-manage your diabetes;
• what adjustments to your diabetes medications or
insulin doses may be necessary before and after
medical procedures or surgery; and
• if you use an insulin pump, are hospital staff familiar
with pump therapy

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2018 Diabetes Canada CPG – Chapter 16. In-hospital Management of Diabetes

Key Messages for People with

Diabetes
• Your blood glucose levels may be higher in hospital than
your usual target range due to a variety of factors,
including the stress of your illness, medications, medical
procedures and infections

• Your diabetes medications may need to be changed

during your hospital stay to manage the changes in
blood glucose, or if medical conditions develop that
make some medications no longer safe to use

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2018 Diabetes Canada CPG – Chapter 16. In-hospital Management of Diabetes

Key Messages for People with

Diabetes
• When you are discharged, make sure that you
have written instructions about:
• changes in your dosage of medications or
insulin injections or any new medications or
treatments;
• how often to check your blood glucose; and
• who to contact if you have difficulty managing
your blood glucose levels

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Visit guidelines.diabetes.ca

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Or download the App

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Diabetes Canada Clinical
Practice Guidelines

http://guidelines.diabetes.ca – for health-care

providers

1-800-BANTING (226-8464)

http://diabetes.ca – for people with diabetes

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