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process improvement. Unfortunately, “best\npractice ”protocols, reviews, and guidelines\nare inconsistently implemented within hos-\npitals (2). To correct this, medical centersstriving for optimal inpatient diabetestreatment should establish protocols andstructured order sets, which include com-\nputerized provider or... | [
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puterized provider order entry (CPOE).\nInstitutions are encouraged to performaudits regularly to monitor proper use andinstitute educational/training programs tokeep staff up to date.\nInitial evaluation should state the type\nof diabetes (i.e., type 1, type 2, gesta-tional, pancreatogenic, drug related, or\nnutrition... | [
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nutrition related) when it is known. Be-\ncause inpatient treatment and dischargeplanning are more effective when pread-mission glycemia is considered, A1Cshould be measured for all people withdiabetes or dysglycemia admitted to the\nhospital if no A1C test result is available\nfrom the previous 3 months (3 –6). In | [
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from the previous 3 months (3 –6). In\naddition, diabetes self-managementknowledge and behaviors should be as-sessed on admission, and diabetes self-management education provided (if\navailable), especially if a new treatment | [
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available), especially if a new treatment\nplan is being considered. Diabetes self-management education should includeknowledge and survival skills needed af-ter discharge, such as medication dosingand administration, glucose monitoring,and recognition and treatment of hypo-\nglycemia (7). Evidence supports pread- | [
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glycemia (7). Evidence supports pread-\nmission treatment of hyperglycemia inpeople scheduled for elective surgery as aneffective means of reducing adverse out-comes (8 –11).\nThe National Academy of Medicine rec-\nommends CPOE to prevent medication-\nrelated errors and to increase medication\nadministration ef ficiency... | [
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administration ef ficiency (12). Systematic\nreviews of randomized controlled trialsusing computerized advice to improveglycemic outcomes in the hospital foundsignificant improvement in the percent-\nage of time individuals spent in the gly-\ncemic goal range, lower mean blood | [
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cemic goal range, lower mean blood\nglucose levels, and no increase in hypo-glycemia (13). Where feasible, thereshould be structured order sets that pro-vide computerized guidance for glycemicmanagement. Insulin dosing algorithms\nusing machine learning and data in the | [
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using machine learning and data in the\nelectronic health record (EHR) currentlyin development show promise for pre-dicting insulin requirements duringhospitalization (14).Diabetes Care Specialists in the\nHospital\nRecommendation\n16.3 When caring for hospitalized peo-\nple with diabetes (with an existing or | [
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ple with diabetes (with an existing or\nnew diagnosis) or stress hyperglycemia,consult with a specialized diabetes orglucose management team when ac-cessible. B\nCare provided by appropriately trained\nspecialists or specialty teams may reduce | [
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the length of stay and improve glycemicand other clinical outcomes (15,16). In ad-dition, the increased risk of 30-day read-mission following hospitalization that hasbeen attributed to diabetes can be re-duced, and costs saved, when inpatientcare is provided by a specialized diabetesmanagement team (15,17,18). In a cro... | [
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team (15,17,18). In a cross-sectional study comparing usual care to | [
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specialists reviewing diabetes cases and\nmaking recommendations virtually throughthe EHR, rates of both hyperglycemia andhypoglycemia were reduced by 30 –40% | [
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(19). Providing inpatient diabetes self-management education and developing adiabetes discharge plan that includes con-tinued access to diabetes medicationsand supplies and ongoing education andsupport are key strategies to improve out-comes (20,21). Details of diabetes careteam composition and other resourcesare avail... | [
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careteam composition and other resourcesare available from the Joint Commission | [
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accreditation program for the hospital\ncare of diabetes, from the Society of Hos-pital Medicine workbook, and from theJoint British Diabetes Societies (JBDS) forInpatient Care Group (22 –24).\nGLYCEMIC GOALS IN\nHOSPITALIZED ADULTS\nRecommendations\n16.4 Insulin Aand/or other therapies\nBshould be initiated or intensi... | [
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Bshould be initiated or intensi fied for\ntreatment of persistent hyperglycemia\nstarting at a threshold of $180 mg/dL\n($10.0 mmol/L) (con firmed on two\noccasions within 24 h) for noncritically\nill (non-ICU) individuals. A\n16.5a Once therapy is initiated, a\nglycemic goal of 140 –180 mg/dL\n(7.8–10.0 mmol/L) is recom... | [
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glycemic goal of 140 –180 mg/dL\n(7.8–10.0 mmol/L) is recommended\nfor most critically ill (ICU) individuals\nwith hyperglycemia. A\n16.5b More stringent glycemic goals, such\nas 110 –140 mg/dL (6.1– 7.8 mmol/L),\nmay be appropriate for selectedcritically ill individuals and are accept-\nable if they can be achieved wi... | [
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able if they can be achieved withoutsignificant hypoglycemia. B\nStandard Defi nitions of Glucose\nAbnormalities\nHyperglycemia in hospitalized individuals isdefined as blood glucose levels >140 mg/dL\n(>7.8 mmol/L) (2). An admission A1C value\n$6.5% ( $48 mmol/mol) suggests that | [
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$6.5% ( $48 mmol/mol) suggests that\nthe onset of diabetes preceded hospitali-zation (see Section 2, “Diagnosis and\nClassifi cation of Diabetes ”). Level 1 hypo-\nglycemia is de fined as a glucose concen-\ntration of 54 –69 mg/dL (3.0 –3.8 mmol/L).\nLevel 2 hypoglycemia is de fined as\na glucose concentration <54 mg/dL | [
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Level 2 hypoglycemia is de fined as\na glucose concentration <54 mg/dL\n(<3.0 mmol/L), which is typically the\nthreshold for neuroglycopenic symptoms.Level 3 hypoglycemia is de fined as a clini-\ncal event characterized by altered mental\nand/or physical functioning that requires | [
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and/or physical functioning that requires\nassistance from another person for recov-ery ( Table 6.4 ) (25,26). Levels 2 and 3\nrequire immediate intervention and cor-rection of low blood glucose. Prompt\ntreatment of level 1 hypoglycemia is\nrecommended as an effort to preventprogression to more signi ficant level 2\nan... | [
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and level 3 hypoglycemia.\nGlycemic Goals\nIn a landmark clinical trial conducted in asurgical intensive care unit (ICU), Vanden Berghe et al. (27) demonstrated that\nan intensive intravenous insulin protocol\nwith a glycemic goal of 80 –110 mg/dL\n(4.4–6.1 mmol/L) reduced mortality by | [
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(4.4–6.1 mmol/L) reduced mortality by\n40% compared with a standard approachof a glycemic goal of 180 –215 mg/dL\n(10–12 mmol/L) in critically ill hospitalized\nindividuals with recent surgery. This studyprovided evidence that active treatmentto lower blood glucose in hospitalized in-dividuals could have immediate bene... | [
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However, a large, multicenter follow-up\nstudy in critically ill hospitalized individu-\nals, the Normoglycemia in Intensive CareEvaluation and Survival Using GlucoseAlgorithm Regulation (NICE-SUGAR) trial(28), led to a reconsideration of the opti-\nmal glucose lowering goal in critical illness. | [
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mal glucose lowering goal in critical illness.\nIn this trial, critically ill individuals random-ized to intensive glycemic management(80–110 mg/dL [4.4– 6.1 mmol/L]) derived\nno signi ficant treatment advantage\ncompared with a group with more mod-\nerate glycemic goals (140 –180 mg/dL | [
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erate glycemic goals (140 –180 mg/dL\n[7.8–10.0 mmol/L]) and had slightly butS296 Diabetes Care in the Hospital Diabetes Care Volume 47, Supplement 1, January 2024\n©AmericanDiabetesAssociation | [
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significantly higher mortality (27.5% vs.\n25%). The intensively treated group had\n10- to 15-fold greater rates of hypogly-\ncemia, which may have contributed to\nthe adverse outcomes noted. The findings\nfrom the NICE-SUGAR trial, supported byseveral meta-analyses and a randomized\ncontrolled trial, showed higher rates... | [
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controlled trial, showed higher rates of hy-\npoglycemia and an increase in mortality\nwith more aggressive glycemic manage-\nment goals compared with moderateglycemic goals (29– 3 1 ) .B a s e do nt h e s er e -\nsults, insulin and/or other therapies shouldbe initiated for the treatment of persis-\ntent hyperglycemia ... | [
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tent hyperglycemia $180 mg/dL ( $10.0\nmmol/L). Once therapy is initiated, a gly-cemic goal of 140 –180 mg/dL (7.8 –10.0\nmmol/L) is recommended for most criticallyill individuals with hyperglycemia. Although\nnot as well supported by data from random-\nized controlled trials, these recommenda- | [
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ized controlled trials, these recommenda-\ntions have been extended to hospitalizedindividuals without critical illness. More\nstringent glycemic goals, such as 110 –140\nmg/dL (6.1 –7.8 mmol/L), may be appropri-\nate for selected individuals (e.g., critically ill\nindividuals undergoing surgery) if it can be\nachieved... | [
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achieved without signi ficant hypoglycemia\n(32,33).\nFor inpatient management of hypergly-\ncemia in noncritical care settings, a glycemic\ngoal of 100– 180 mg/dL (5.6– 10.0 mmol/L)\nis recommended, whether it is new hyper-glycemia (e.g., newly diagnosed diabetesor stress hyperglycemia) or hyperglycemia\nrelated to dia... | [
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related to diabetes prior to admission (2).\nIt has been found that fasting glucose\nlevels<100 mg/dL ( <5.6 mmol/L) are\npredictors of hypoglycemia within thenext 24 h (34). Glycemic levels up to 250\nmg/dL (13.9 mmol/L) may be acceptable\nin selected populations (terminally ill indi-\nviduals with short life expectan... | [
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0.025300823152065277,
-0.05430396646261215,
0.0099... |
viduals with short life expectancy, ad-\nvanced kidney failure [and/or on dialysis],\nhigh risk for hypoglycemia, and/or labileglycemic excursions). In these individu-\nals, less aggressive treatment goals that\nw o u l dh e l pa v o i ds y m p t o m a t i ch y p o g l y -\ncemia and/or hyperglycemia are often\nappropr... | [
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0.017297280952334404,
-0.018285484984517097,
... |
appropriate. Clinical judgment combined\nwith ongoing assessment of clinical sta-\ntus, including changes in the trajectory of\nglucose measures, illness severity, nutri-\ntional status, or concomitant medicationsthat might affect glucose levels (e.g., gluco-\ncorticoids), may be incorporated into the\nday-to-day decis... | [
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day-to-day decisions regarding treatment\ndosing.GLUCOSE MONITORING\nIn hospitalized individuals with diabetes\nwho are eating, point-of-care (POC) bloodglucose monitoring should be performedbefore meals; in those not eating, glucose\nmonitoring is advised every 4 –6h( 2 6 ) .\nMore frequent POC blood glucose moni- | [
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0.004916... |
More frequent POC blood glucose moni-\ntoring ranging from every 30 min to every2 h is the required standard for safe useof intravenous insulin therapy.\nHospital blood glucose monitoring should\nb ep e r f o r m e dw i t hU . S .F o o da n dD r u gA d -ministration (FDA) –approved POC hospital- | [
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0.015... |
calibrated glucose monitoring systems (35).POC blood glucose meters are not as accu-rate or as precise as laboratory glucose ana-\nlyzers, and capillary blood glucose readings | [
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0.037... |
lyzers, and capillary blood glucose readings\na r es u b j e c tt oa r t i f a c t sd u et op e r f u s i o n ,edema, anemia/erythrocytosis, and severalmedications commonly used in the hospital(35) ( Table 7.1 ). The FDA has established\nstandards for capillary (fi nger-stick) POC glu- | [
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0.0530... |
standards for capillary (fi nger-stick) POC glu-\ncose monitoring in the hospital (35). The bal-ance between analytic requirements (e.g.,accuracy, precision, and interference) andclinical requirements (e.g., rapidity, simplic-ity, and POC) has not been uniformly re-\nsolved (35 –38), and most hospitals have\narrived at ... | [
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0.073482707... |
arrived at their own policies to balance\nthese parameters. It is critically importantthat devices selected for in-hospital use, andthe workfl ow through which they are ap- | [
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plied, undergo careful analysis of perfor-mance and reliability and ongoing qualityassessments (38). Recent studies indicatethat POC measures provide adequate infor-mation for usual practice, with only rare in-stances where care has been compromised(36,37). Best practice dictates that any glu-\ncose result that does no... | [
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0.05... |
cose result that does not correlate with the\nindividual ’s clinical status should be con-\nfirmed by measuring a sample in the clinical\nlaboratory, particularly for asymptomatic hy-poglycemic events.\nContinuous Glucose Monitoring\nRecommendations\n16.6 In people with diabetes using a\npersonal continuous glucose moni... | [
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... |
personal continuous glucose monitor-\ning (CGM) device, the use of CGMshould be continued during hospitali-\nzation if clinically appropriate, with\nconfirmatory point-of-care (POC) glu- | [
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0.0007137990323826671,
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0.04607... |
confirmatory point-of-care (POC) glu-\ncose measurements for insulin dosingdecisions and hypoglycemia assess-ment, if resources and training areavailable, and according to an institu-tional protocol. B16.7 For people with diabetes using an\nautomated insulin delivery (AID) system | [
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0.06710992753505707,
-0.06312771141529083,
0.0000... |
automated insulin delivery (AID) system\nalong with CGM, the use of AID andCGM should be continued during hospi-talization if clinically appropriate, withconfirmatory POC blood glucose meas-\nurements for insulin dosing decisionsand hypoglycemia assessment, if resour-\nces and training are available, and ac-\ncording to... | [
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-0.07412724941968918,
0.05... |
cording to an institutional protocol. C\nSeveral studies have demonstrated that\ninpatient use of continuous glucose moni-\ntoring (CGM) has advantages over POC\nglucose monitoring in detecting hypogly-\ncemia, particularly nocturnal, prolonged\nand/or asymptomatic hypoglycemia (39 –41),\nand in reducing recurrent hypo... | [
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0.0... |
and in reducing recurrent hypoglycemia\n(42,43). However, at this time, initiating\nuse of a new CGM device has not been\napproved by the FDA. During the corona-\nvirus disease 2019 (COVID-19) pandemic,many institutions used CGM in ICU and\nnon-ICU settings, with the aim of mini-\nmizing exposure time and saving person... | [
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mizing exposure time and saving personal\nprotective equipment, under an FDA pol-\nicy of enforcement discretion (44,45). Dataon the safety and effi cacy of real-time\nCGM use in the hospital, particularly with\nimplementation of remote monitoring\n(e.g., a glucose telemetry system), is\ngrowing (42,43,45– 50).\nContinu... | [
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0.0488160103559494,
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-0.0008623574394732714,
0.04587... |
growing (42,43,45– 50).\nContinuation of personal CGM device\nuse, particularly for people with type 1 or\ntype 2 diabetes treated with intensive ther-\napy at increased risk for hypoglycemia\nduring hospitalization, is recommended.\nConfirmatory POC capillary glucose test-\ning, using hospital-calibrated glucose me- | [
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0.0... |
ing, using hospital-calibrated glucose me-\nters, is recommended for insulin dosing\nand hypoglycemia assessment (e.g., hy-\nbrid testing protocols) (51). People with\ndiabetes should be counseled aboutmeaningful use of trend arrows and\nalarms and about notifying nursing staff\nfor con firmation of these events with | [
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0.077939... |
for con firmation of these events with\nPOC capillary glucose testing. Similarly,\ncontinuation of AID systems should besupported during hospitalization, when\nclinically appropriate, and with proper\nstaff training and supervision (41,45). Ob-\nservational studies have demonstrated | [
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servational studies have demonstrated\nimprovements in patient satisfaction andimproved detection of glycemic excursions\n(40,47). If the reason for admission is sus-\npected to be related to device malfunction\nor lack of adequate education/training or | [
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or lack of adequate education/training or\nuse, consultation with the endocrinology/diabetesjournals.org/care Diabetes Care in the Hospital S297\n©AmericanDiabetesAssociation | [
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diabetes care team or diabetes care and\neducation specialists, if available, is rec-ommended. Hospitals are encouraged todevelop institutional policies and have\ntrained personnel with knowledge of dia-\nbetes technology. Recent review articlesprovide details on accuracy, interfer-\nences, precautions, and contraindic... | [
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ences, precautions, and contraindications\nof diabetes technology devices in thehospital setting (50,51).\nFor more information on CGM, see\nSection 7, “Diabetes Technology. ”\nGLUCOSE-LOWERING TREATMENT\nIN HOSPITALIZED PATIENTS\nAn individualized approach for glycemic\nmanagement is encouraged throughout\nthe hospita... | [
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the hospital stay and should take into\nconsideration several predictive factorsfor achieving glycemic goals, such as\nprior home use and dose of insulin or\nnoninsulin therapy, expected level of in-sulin resistance, prior A1C, current glu-\ncose levels, oral intake, and duration of\ndiabetes.\nInsulin Therapy\nRecomme... | [
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diabetes.\nInsulin Therapy\nRecommendations\n16.8 Basal insulin or a basal plus bolus\ncorrection insulin plan is the preferred\ntreatment for noncritically ill hospital-\nized individuals with poor oral intake\nor those who are taking nothing bymouth. A\n16.9 An insulin plan with basal, pran-\ndial, and correction com... | [
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0.0133... |
dial, and correction components is the\npreferred treatment for most noncriti-\ncally ill hospitalized individuals withadequate nutritional intake. A\n16.10 Sole use of a correction or\nsupplemental insulin without basalinsulin (formerly referred to as a\nsliding scale) in the inpatient setting\nis discouraged. A\nCrit... | [
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is discouraged. A\nCritical Care Setting\nContinuous intravenous insulin infusion\nis the most effective method for achiev-ing speci fic glycemic goals and avoiding\nhypoglycemia in the critical care setting.\nIntravenous insulin infusions should be\nadministered using validated written orcomputerized protocols that all... | [
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0.003... |
prede fined adjustments in the insulin in-\nfusion rate based on glycemic fluctua-\ntions and immediate past and current\ninsulin infusion rates (52). For diabetic\nketoacidosis (DKA) and hyperglycemichyperosmolar state (HHS) management, | [
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continuous intravenous insulin infusion isgiven for correction of hyperglycemia, hyper-ketonemia, and acid-base disorder followingafixed-rate intravenous insulin infusion (53)\nor nurse-driven protocol with a variable ratebased on glucose values (54). Individualswith mild and uncomplicated DKA can bemanaged with subcuta... | [
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sulin doses given every 1 –2 h (55).\nNoncritical Care Setting\nIn most instances, insulin is the preferred\ntreatment for hyperglycemia in hospital-ized individuals. In certain circumstances,\nit may be appropriate to continue home | [
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0.048... |
it may be appropriate to continue home\noral glucose-lowering medications, suchas dipeptidyl peptidase 4 inhibitors (DPP-4i)(52,56). If oral medications are held in the\nhospital but will be reinstated after dis-\ncharge, there should be a protocol forguiding resumption of home medications1–2 days prior to discharge. F... | [
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taking insulin, several reports indicate thatinpatient use of insulin pens is safe andmay improve nurse satisfaction whensafety protocols, including nursing edu-\ncation, are in place to guarantee single-\nperson use (57 –61).\nOutside of critical care units, scheduled\nsubcutaneous insulin orders are recom-mended for ... | [
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0.034583... |
glycemia in people with diabetes and\nhyperglycemia. Use of insulin analogs orhuman insulin results in similar glycemicoutcomes in the hospital setting but may\nincrease severe hypoglycemic events (62).\nThe use of subcutaneous rapid- or short-acting insulin before meals, or every 4 –6h\nif no meals are given or if the... | [
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if no meals are given or if the individual is\nreceiving continuous enteral/parenteral\nnutrition, is indicated to correct or pre-vent hyperglycemia. Basal insulin, or abasal plus bolus correction schedule, isthe preferred treatment for noncritically\nill hospitalized individuals with inadequate | [
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ill hospitalized individuals with inadequate\nor restricted oral intake. An insulin sched-ule with basal, prandial, and correctioncomponents is the preferred treatment\nfor most noncritically ill hospitalized people\nwith diabetes with adequate nutritionalintake.\nA randomized controlled trial has shown | [
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A randomized controlled trial has shown\nthat basal plus bolus treatment improvedglycemic outcomes and reduced hospitalcomplications compared with a correctionor supplemental insulin without basal insu-lin (formerly known as sliding scale) for\npeople with type 2 diabetes admitted for | [
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... |
people with type 2 diabetes admitted for\ngeneral surgery (63). Prolonged use ofcorrection or supplemental insulin withoutbasal insulin as the sole treatment of hy-perglycemia is strongly discouraged in the\ninpatient setting, with the exception of\npeople with type 2 diabetes in noncritical\ncare with mild hyperglycem... | [
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care with mild hyperglycemia (2,64,65).\nA prospective randomized inpatient\nstudy of 70/30 intermediate-acting (NPH)/regular insulin mixture versus basal-bolus\ntherapy showed comparable glycemic out-comes but signi ficantly increased hypogly-\ncemia in the group receiving insulin mixture(66). Therefore, insulin mixtur... | [
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25, 70/30, or 50/50 insulins are not rou-\ntinely recommended for in-hospital use.\nData on the use of glargine U-300\nand degludec U-100 or U-200 in the in-patient and perioperative settings arelimited. A few studies have shown that\nthey demonstrated similar ef ficacy and\nsafety compared with glargine U-100(67–69). A... | [
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0... |
able evidence for weekly insulin use inhospital or surgical settings.\nType 1 Diabetes\nF o rp e o p l ew i t ht y p e1d i a b e t e s ,d o s i n g\ninsulin based solely on premeal glucose\nlevels does not account for basal insulin\nrequirements or caloric intake, increasingthe risk of both hypoglycemia and hyper- | [
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0.0172... |
glycemia. Typically, basal insulin dosing is\nbased on body weight and expected sen-\nsitivity to insulin, with some evidence\nthat people with renal insuf ficiency\nshould be treated with lower insulindoses (70,71). An insulin schedule withbasal and correction components is nec-\nessary for all hospitalized individuals... | [
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0.004229... |
essary for all hospitalized individuals with\ntype 1 diabetes, even when taking noth-\ning by mouth, with the addition of pran-\ndial insulin when eating. Policies and best\npractice alerts in the EHR should be put in\nplace to ensure that basal insulin (givensubcutaneously, via insulin pump or by in-\nsulin infusion) ... | [
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0.0... |
sulin infusion) is not held for people with\ntype 1 diabetes, especially during care\ntransitions, and that ongoing prescriber\nand nursing education is provided (60).\nTransitioning From Intravenous to\nSubcutaneous Insulin\nWhen discontinuing intravenous insulin, a\ntransition protocol is recommended, as it\nis assoc... | [
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0.0861... |
is associated with less morbidity and\nlower costs of care. Subcutaneous basal\ninsulin should be given 2 h before intrave-\nnous infusion is discontinued, with theaim of minimizing rebound hyperglycemia\n(2,72,73).S298 Diabetes Care in the Hospital Diabetes Care Volume 47, Supplement 1, January 2024\n©AmericanDiabetes... | [
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0.0074... |
Emerging data from several studies\nshow that the administration of a low dose\n(0.15–0.3 units/kg) of basal insulin analog\nin addition to intravenous insulin infusionmay reduce the duration of insulin infusionand length of hospital stay and prevent re-bound hyperglycemia without increasedrisk of hypoglycemia (74 –76)... | [
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0.008645554073154926,
0.006067... |
For transitioning, the total daily dose of\nsubcutaneous insulin can be calculatedbased on the insulin infusion rate duringthe prior 6 –8 h when stable glycemic goals\nwere achieved, based on prior home insulin\ndose, or following a weight-based approach(72,73). For people being transitioned toconcentrated insulin (U-2... | [
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-0.... |
U-500) in the inpatient setting, it is impor-\ntant to ensure correct dosing by using a sep-arate pen or vial for each person and bymeticulous pharmacy and nursing supervi-sion of the dose administered (77,78).\nNoninsulin Therapies\nRecommendation\n16.11 For people with type 2 diabetes\nhospitalized with heart failure... | [
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0.05248... |
hospitalized with heart failure, it is\nrecommended that use of a sodium –\nglucose cotransporter 2 inhibitor be\ninitiated or continued during hospital-\nization and upon discharge, if thereare no contraindications and after re-covery from the acute illness. A\nThe safety and ef ficacy of noninsulin\nglucose-lowering t... | [
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0.018171941861510277,
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0.11541441828012466,
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0.0... |
glucose-lowering therapies in the hospital\nsetting has expanded recently (79 –83). A\nrandomized trial and an observational study\nhave demonstrated the safety and ef ficacy\nof DPP-4i in speci fic groups of hospitalized\npeople with diabetes (84,85). The use of | [
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0.15716005861759186,
0.020393332466483116,
0.02799520082771778,
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-0.0055... |
people with diabetes (84,85). The use of\nDPP-4i with or without basal insulin may bea safer and simpler plan for people withmild to moderate hyperglycemia on admis-sion (e.g., admission glucose <180–200\nmg/dL), with reduced risk of hypoglycemia\n(79,85,86). Of note, the FDA states that | [
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(79,85,86). Of note, the FDA states that\nhealth care professionals should considerdiscontinuing saxagliptin and alogliptin inpeople who develop heart failure (87). Dataon the inpatient use of glucagon-like pep-tide 1 (GLP-1) receptor agonists are stillmostly limited to research studies and selectpopulations that are m... | [
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For people with type 2 diabetes hospital-\nized with heart failure, it is recommendedthat use of a sodium –glucose cotransporter\n2 (SGLT2) inhibitor be initiated or continued\nduring hospitalization and upon discharge,if there are no contraindications and after\nrecovery from the acute illness (88,89). | [
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recovery from the acute illness (88,89).\nSGLT2 inhibitors should be avoided in casesof severe illness, in people with ketonemiaor ketonuria, and during prolonged fastingand surgical procedures (90– 93). Proac- | [
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tive adjustment of diuretic dosing is rec-ommended during hospitalization and/ordischarge, especially in collaboration witha cardiology/heart failure consult team(90–93). The FDA has warned that SGLT2\ninhibitors should be stopped 3 days before\nscheduled surgeries (4 days in the case of\nertugli flozin) (94).\nHYPOGLYC... | [
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0.023108849301934242,
0.025777297094464302,
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0.0... |
ertugli flozin) (94).\nHYPOGLYCEMIA\nRecommendations\n16.12 A hypoglycemia management\nprotocol should be adopted and imple-\nmented by each hospital or hospital\nsystem. A plan for preventing and treat-\ning hypoglycemia should be established\nfor each individual. Episodes of hypo-\nglycemia in the hospital should be\n... | [
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0.005... |
documented in the electronic health\nrecord and tracked for quality assess-\nment and quality improvement. E\n16.13 Treatment plans should be re-\nviewed and changed as necessary to\nprevent hypoglycemia and recurrent\nhypoglycemia when a blood glucose\nvalue of <70 mg/dL ( <3.9 mmol/L) is\ndocumented. C\nPeople with o... | [
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0.0553901307284832,
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0.000... |
documented. C\nPeople with or without diabetes may ex-\nperience hypoglycemia in the hospital\nsetting. While hypoglycemia is associatedwith increased mortality (95,96), in manycases, it is a marker of an underlying dis-\nease rather than the cause of fatality. | [
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However, hypoglycemia is a severe conse-quence of dysregulated metabolism and/ordiabetes treatment, and it is imperativethat it be minimized during hospitalization.Many episodes of inpatient hypoglycemiaare preventable. A hypoglycemia preven-tion and management protocol should beadopted and implemented by each hos-pita... | [
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0.0286... |
beadopted and implemented by each hos-pital or hospital system. A standardizedhospital-wide, nurse-initiated hypoglycemia | [
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treatment protocol should be in place to\nimmediately address blood glucose levels<70 mg/dL ( <3.9 mmol/L) (97,98). In addi- | [
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tion, individualized plans for preventingand treating hypoglycemia for each individ-ual should also be developed. An AmericanDiabetes Association consensus statementrecommends that an individual ’st r e a t m e n tplan be reviewed any time a blood glucose\nvalue of <70 mg/dL ( <3.9 mmol/L) occurs,\nas this level often ... | [
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as this level often predicts subsequent level\n3 hypoglycemia (99). Episodes of hypoglyce-\nmia in the hospital should be documented\nin the EHR and tracked (1). A key strategy is\nembedding hypoglycemia treatment into allinsulin and insulin infusion orders.\nInpatient Hypoglycemia: Risk\nFactors, Treatment, and Preven... | [
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Inpatient Hypoglycemia: Risk\nFactors, Treatment, and Prevention\nInsulin is one of the most common medi-\ncations causing adverse events in hospital-\nized individuals. Errors in insulin dosing,missed doses, and/or administration errors\nincluding incorrect insulin type and incor-\nrect timing of dose occur relatively... | [
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0.0172758884... |
rect timing of dose occur relatively fre-\nquently (100 –102) and include prescriber\n(ordering), pharmacy (dispensing), and\nnursing (administration) errors. Common\npreventable sources of iatrogenic hypogly-\ncemia are improper prescribing of other\nglucose-lowering medications and inap- | [
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glucose-lowering medications and inap-\npropriate management and follow-up ofthefirst episode of hypoglycemia (103). Kid-\nney failure is an important risk factor for hy-poglycemia in the hospital (104), possibly\nas a result of decreased insulin clearance.\nStudies of “bundled” preventive therapies,\nincluding proactiv... | [
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0.0858122855424881,
0.10058770328760147,
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-0.010538168251514435,
0.03717772290110588,
0.0824551209807396,
-0.044449131935834885,
0.012136812... |
including proactive surveillance of glycemic\noutliers and an interdisciplinary data-driven\napproach to glycemic management, showed\nthat hypoglycemic episodes in the hospi-\ntal could be reduced or prevented. Com-pared with baseline, studies found that\nhypoglycemic events decreased by\n56–80% (98,105,106). The Joint... | [
0.06092449277639389,
0.12069890648126602,
-0.013262658379971981,
0.0468083880841732,
0.008143248967826366,
-0.020283890888094902,
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-0.05567163974046707,
-0.0246034637093544,
0.030330106616020203,
0.05481066182255745,
-0.04119039326906204,
-0.0461254... |
56–80% (98,105,106). The Joint Commis-\nsion, a global quality improvement andpatient safety in health care organiza-tion, recommends that all hypoglycemic\nepisodes be evaluated for a root cause\nand the episodes be aggregated and re-\nviewed to address systemic issues (23).\nIn addition to errors with insulin treatme... | [
0.04118354991078377,
0.0429811030626297,
-0.05447778478264809,
0.062031954526901245,
-0.02647380344569683,
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0.0271149892359972,
0.09872730076313019,
-0.06154845282435417,
-0.02888408862054348,
0.0009950508829206228,
0.0751589983701706,
0.003562756348401308,
-0.0203318... |
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