Last updated March 14, 2022

Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Setting

Recommendations

Diagnosis and recognition of hyperglycemia and diabetes in the hospital setting

We recommend that clinicians assess all patients admitted to the hospital for a history of diabetes. When present, this diagnosis should be clearly identified in the medical record. (1, VL)
700
We suggest that all patients, independent of a prior diagnosis of diabetes, have laboratory blood glucose (BG) testing on admission. (2, VL)
700
We recommend that patients without a history of diabetes with BG greater than 7.8 mmol/liter (140 mg/dl) be monitored with bedside point of care (POC) testing for at least 24 to 48 h. Those with BG greater than 7.8 mmol/liter require ongoing POC testing with appropriate therapeutic intervention. (1, VL)
700
We recommend that in previously normoglycemic patients receiving therapies associated with hyperglycemia, such as corticosteroids or octreotide, enteral nutrition (EN) and parenteral nutrition (PN) be monitored with bedside POC testing for at least 24 to 48 h after initiation of these therapies. Those with BG measures greater than 7.8 mmol/liter (140 mg/dl) require ongoing POC testing with appropriate therapeutic intervention. (1, VL)
700
We recommend that all inpatients with known diabetes or with hyperglycemia (>7.8 mmol/liter) be assessed with a hemoglobin A1C (HbA1C) level if this has not been performed in the preceding 2–3 months. (1, VL)
700

Monitoring glycemia in the non-critical care setting

We recommend bedside capillary POC testing as the preferred method for guiding ongoing glycemic management of individual patients. (1, L)
700
We recommend the use of BG monitoring devices that have demonstrated accuracy of use in acutely ill patients. (1, VL)
700
We recommend that timing of glucose measures match the patient's nutritional intake and medication regimen. (1, VL)
700
We suggest the following schedules for POC testing: before meals and at bedtime in patients who are eating, or every 4–6 h in patients who are NPO [receiving nothing by mouth (nil per os)] or receiving continuous enteral feeding. (2, VL)
700

Glycemic targets in the non-critical care setting

We recommend a premeal glucose target of less than 140 mg/dl (7.8 mmol/liter) and a random BG of less than 180 mg/dl (10.0 mmol/liter) for the majority of hospitalized patients with non-critical illness. (1, L)
700
We suggest that glycemic targets be modified according to clinical status. For patients who are able to achieve and maintain glycemic control without hypoglycemia, a lower target range may be reasonable. For patients with terminal illness and/or with limited life expectancy or at high risk for hypoglycemia, a higher target range (BG < 11.1 mmol/liter or 200 mg/dl) may be reasonable. (2, VL)
700
For avoidance of hypoglycemia, we suggest that antidiabetic therapy be reassessed when BG values fall below 5.6 mmol/liter (100 mg/dl). Modification of glucose-lowering treatment is usually necessary when BG values are below 3.9 mmol/liter (70 mg/dl). (2, VL)
700

Management of hyperglycemia in the non-critical care setting

Medical nutrition therapy

We recommend that MNT be included as a component of the glycemic management program for all hospitalized patients with diabetes and hyperglycemia. (1, VL)
700
We suggest that providing meals with a consistent amount of carbohydrate at each meal can be useful in coordinating doses of rapid-acting insulin to carbohydrate ingestion. (2, VL)
700

We suggest that providing meals with a consistent amount of carbohydrate at each meal can be useful in coordinating doses of rapid-acting insulin to carbohydrate ingestion.

We recommend insulin therapy as the preferred method for achieving glycemic control in hospitalized patients with hyperglycemia. (1, L)
700
We suggest the discontinuation of oral hypoglycemic agents and initiation of insulin therapy for the majority of patients with type 2 diabetes at the time of hospital admission for an acute illness. (2, VL)
700
We suggest that patients treated with insulin before admission have their insulin dose modified according to clinical status as a way of reducing the risk for hypoglycemia and hyperglycemia. (2, VL)
700

Pharmacological therapy

We recommend that all patients with diabetes treated with insulin at home be treated with a scheduled sc insulin regimen in the hospital. (1, H)
700
We suggest that prolonged use of sliding scale insulin (SSI) therapy be avoided as the sole method for glycemic control in hyperglycemic patients with history of diabetes during hospitalization. (2, VL)
700
We recommend that scheduled sc insulin therapy consist of basal or intermediate-acting insulin given once or twice a day in combination with rapid- or short-acting insulin administered before meals in patients who are eating. (1, M)
700
We suggest that correction insulin be included as a component of a scheduled insulin regimen for treatment of BG values above the desired target. (2, VL)
700

Transition from hospital to home

We suggest reinstitution of preadmission insulin regimen or oral and non-insulin injectable antidiabetic drugs at discharge for patients with acceptable preadmission glycemic control and without a contraindication to their continued use. (2, VL)
700
We suggest that initiation of insulin administration be instituted at least one day before discharge to allow assessment of the efficacy and safety of this transition. (2, VL)
700
We recommend that patients and their family or caregivers receive both written and oral instructions regarding their glycemic management regimen at the time of hospital discharge. These instructions need to be clearly written in a manner that is understandable to the person who will administer these medications. (1, L)
700

Special situations

Transition from iv continuous insulin infusion (CII) to sc insulin therapy

We recommend that all patients with type 1 and type 2 diabetes be transitioned to scheduled sc insulin therapy at least 1–2 h before discontinuation of CII. (1, H)
700
We recommend that sc insulin be administered before discontinuation of CII for patients without a history of diabetes who have hyperglycemia requiring more than 2 U/h. (1, H)
700
We recommend POC testing with daily adjustment of the insulin regimen after discontinuation of CII. (1, M)
700

Patients receiving EN or PN

We recommend that POC testing be initiated for patients with or without a history of diabetes receiving EN and PN. (1, H)
700
We suggest that POC testing can be discontinued in patients without a prior history of diabetes if BG values are less than 7.8 mmol/liter (140 mg/dl) without insulin therapy for 24–48 h after achievement of desired caloric intake. (2, VL)
700
We suggest that scheduled insulin therapy be initiated in patients with and without known diabetes who have hyperglycemia, defined as BG greater than 7.8 mmol/liter (140 mg/dl), and who demonstrate a persistent requirement (i.e. >12 to 24 h) for correction insulin. (2, VL)
700

Perioperative BG control

We recommend that all patients with type 1 diabetes who undergo minor or major surgical procedures receive either CII or sc basal insulin with bolus insulin as required to prevent hyperglycemia during the perioperative period. (1, H)
700
We recommend discontinuation of oral and non-insulin injectable antidiabetic agents before surgery with initiation of insulin therapy in those who develop hyperglycemia during the perioperative period for patients with diabetes. (1, VL)
700
When instituting sc insulin therapy in the postsurgical setting, we recommend that basal (for patients who are NPO) or basal bolus (for patients who are eating) insulin therapy be instituted as the preferred approach. (1, M)
700

Glucocorticoid-induced diabetes

We recommend that bedside POC testing be initiated for patients with or without a history of diabetes receiving glucocorticoid therapy. (1, M)
700
We suggest that POC testing can be discontinued in nondiabetic patients if all BG results are below 7.8 mmol/liter (140 mg/dl) without insulin therapy for a period of at least 24–48 h. (2, VL)
700
We recommend that insulin therapy be initiated for patients with persistent hyperglycemia while receiving glucocorticoid therapy. (1, L)
700
We suggest CII as an alternative to sc insulin therapy for patients with severe and persistent elevations in BG despite use of scheduled basal bolus sc insulin. (2, VL)
700

Recognition and management of hypoglycemia in the hospital setting

We recommend that glucose management protocols with specific directions for hypoglycemia avoidance and hypoglycemia management be implemented in the hospital. (1, L)
700
We recommend implementation of a standardized hospital-wide, nurse-initiated hypoglycemia treatment protocol to prompt immediate therapy of any recognized hypoglycemia, defined as a BG below 3.9 mmol/liter (70 mg/dl). (1, L)
700
We recommend implementation of a system for tracking frequency of hypoglycemic events with root cause analysis of events associated with potential for patient harm. (1, L)
700

Implementation of a glycemic control program in the hospital

We recommend that hospitals provide administrative support for an interdisciplinary steering committee targeting a systems approach to improve care of inpatients with hyperglycemia and diabetes. (1, M)
700
We recommend that each institution establish a uniform method of collecting and evaluating POC testing data and insulin use information as a way of monitoring the safety and efficacy of the glycemic control program. (1, VL)
700
We recommend that institutions provide accurate devices for glucose measurement at the bedside with ongoing staff competency assessments. (1, VL)
700

Patient and professional education

We recommend diabetes self-management education targeting short-term goals that focus on survival skills: basic meal planning, medication administration, BG monitoring, and hypoglycemia and hyperglycemia detection, treatment, and prevention. (1, VL)
700
We recommend identifying resources in the community to which patients can be referred for continuing diabetes self-management education after discharge. (1, VL)
700
We recommend ongoing staff education to update diabetes knowledge, as well as targeted staff education whenever an adverse event related to diabetes management occurs. (1, VL)
700

Recommendation Grading

Overview

Title

Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Setting

Authoring Organization

Publication Month/Year

January 1, 2012

Supplemental Implementation Tools

Quick-Reference Guide

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Older adult

Health Care Settings

Hospital, Long term care

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Management, Treatment

Diseases/Conditions (MeSH)

D006943 - Hyperglycemia

Keywords

diabetes, hyperglycemia

Source Citation

Guillermo E. Umpierrez, Richard Hellman, Mary T. Korytkowski, Mikhail Kosiborod, Gregory A. Maynard, Victor M. Montori, Jane J. Seley, Greet Van den Berghe, Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Setting: An Endocrine Society Clinical Practice Guideline, The Journal of Clinical Endocrinology & Metabolism, Volume 97, Issue 1, 1 January 2012, Pages 16–38, https://doi.org/10.1210/jc.2011-2098