Guidelines Urge Early In-Hospital Glucose Control


WASHINGTON — Hyperglycemia should be identified and vigorously treated in all hospitalized patients to improve medical and surgical outcomes, according to new guidelines from the American Association of Clinical Endocrinologists.

The guidelines, presented at the conclusion of a 2-day consensus conference sponsored by the American Association of Clinical Endocrinologists, the American College of Endocrinology, and the American Diabetes Association, provide specific strategies for achieving previously recommended targets in all patients who have hyperglycemia upon admission, not just those with known diabetes.

Those previously recommended targets—iterated in a position statement from the American College of Endocrinology and the American Diabetes Association—include a blood glucose limit of no more than 110 mg/dL for patients in the intensive care unit; a fasting glucose level of 110 mg/dL for patients in noncritical care units; and a postprandial glucose limit of 180 mg/dL in noncritical care patients who can eat (Endocr. Pract. 2004;10:77–82).

“People with diabetes and high blood sugar [represent] an increasing percentage of hospitalized patients with serious problems which need special attention. …The findings and conclusions of this important conference will help to determine health care policies to improve patient care in all of our nation's hospitals,” Dr. Rhoda H. Cobin of Mount Sinai School of Medicine, New York, and ACE president, said at a press briefing following the meeting.

Among the findings and recommendations:

▸ Elevated blood sugars should be identified in all hospitalized patients.

▸ Hyperglycemia should be vigorously treated as soon as it is detected.

▸ Structured protocols for aggressive control of blood sugar in both intensive care units and other hospital settings should be implemented.

▸ Successful protocols for intensive glycemic control are available for use in intensive care units and other hospital settings. Several published protocols are available, and the guidelines allow institutions to choose those that best fit their resources and staff expertise: “The exact protocol is probably less important than its presence in an institution,” the guidelines state.

No longer acceptable, however, are the traditional “sliding scale” regimens. According to the document—and participants at the consensus conference—this “retroactive form of insulin replacement” is “inherently illogical,” has been associated with increased glycemic excursions, and is “potentially very dangerous” in certain settings, particularly among patients with type 1 diabetes.

The guidelines go on to state that when subcutaneous insulin is used, it should be done in the most physiologic way possible to achieve the best control. Use of oral hypoglycemic agents is discouraged for most hospitalized patients, although it may be acceptable in certain stable patients who are eating. Although hypoglycemia may be unavoidable as a result of aggressive treatment, it is usually mild, transient, and easily treated, and harm can be avoided, particularly when structured plans are in place.

Plans should be implemented for a smooth transition to outpatient care with appropriate diabetes management, particularly in patients who are newly diagnosed with diabetes during their hospital stay, the guidelines state. Finally, the National Diabetes Quality Improvement Alliance should develop performance measures for the inpatient management of hyperglycemia and submit the measures to the National Quality Forum for the approval process which establishes these measures as standards for the nation.

The guidelines also encourage purchasers, payers, and accreditors to adopt standardized measures for use in their publicly reported measure sets, disease management accreditation programs, and pay-for-performance programs.

As a first step, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is set to launch a voluntary inpatient diabetes care certification program in the first half of 2006, Charles A. Mowll, JCAHO's executive vice president for business development, government, and external relations announced at the conference.

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