Diabetes FAQs
Developed by the Diabetes Clinical Stream
December 2013
Frequently asked questions about diabetes management
for adult inpatients
In general, the goals for managing adult inpatients with diabetes are to:
 Avoid hypoglycaemia
 Avoid severe hyperglycaemia, volume depletion, and electrolyte abnormalities
 Ensure adequate nutrition
 Assess patient educational needs and address deficiencies
Patients with existing type 1 or type 2 diabetes mellitus are frequently admitted to a hospital, usually for
treatment of conditions other than the diabetes. Glycaemic control is likely to become unstable in these
patients, not only because of the stress of the illness or procedure, but also because of the concomitant
changes in dietary intake and physical activity.
Patients who did not have a diagnosis of diabetes prior to admission, may be diagnosed with type 1 or type
2, including steroid-induced or pancreatitis-induced diabetes.
The following questions and answers have been developed by the Diabetes Clinical Stream to assist
generalist staff to effectively care for adult patients with existing diabetes or with newly diagnosed diabetes
whilst in hospital and to adequately prepare these patients for discharge.
Q. Why is it important to control blood glucose levels (BGL) while in hospital?
The aim of diabetes treatment is to keep blood glucose levels as close to target as possible.
Q. Will a patient’s blood glucose targets be kept the same or be different while hospitalised?
It is possible that the blood glucose targets may be different while hospitalised.
Q. What are the glycaemic (BGL) goals while in hospital?
More stringent goals may be appropriate for stable patients with previous good glycaemic control, and the
goal should be set somewhat higher for older patients and those with severe comorbidities where the
heightened risk of hypoglycaemia may outweigh any potential benefit.
The glycaemic goals will be dependent on the type of diabetes and the treatment regimen:
Type 2 patients on diet alone or on oral diabetes medication
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Patients treated by diet alone usually need no specific hypoglycaemic therapy whilst in hospital.
Frequent blood glucose monitoring is warranted to prevent serious hyperglycaemia from being
unrecognised.
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Patients treated with oral diabetes medications can continue their usual drug regimen in some
circumstances (patient eating, glucose well controlled, and no contraindication to oral agents)
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If BGL is poorly controlled with the usual oral agents or if the patient is not eating, oral diabetes
medications should be discontinued and insulin initiated.
Type 2 patients treated with insulin
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Insulin therapy should be continued in all patients already taking it, in order to maintain a
reasonably constant basal level of circulating insulin. Otherwise, severe hyperglycaemia or
ketoacidosis can occur, even in patients labelled as having type 2 diabetes but who have become
significantly insulin deficient over a prolonged disease course.
Type 1 diabetes

Patients with type 1 diabetes require insulin at all times, whether or not they are eating, to prevent
hyperglycaemia which can lead to diabetic ketoacidosis (DKA).
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Blood glucose concentrations tend to fluctuate more during the course of an illness or procedure. It
is also very important to avoid hypoglycaemia, even if the consequence is a temporary modest rise
in the blood glucose concentration.
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For subcutaneous insulin, sole insulin sliding-scale regimens should never be used. Optimally, basal
insulin (glargine, detemir, or NPH) should be combined with prandial insulin and correction insulin
(rapid or short-acting insulin).
Q. What inpatient blood glucose targets should be aimed for?
What glucose targets should be aimed for in acute Myocardial Infarction?
 Patients admitted to hospital with myocardial infarction who have hyperglycaemia, should be
treated to achieve and maintain glucose levels less than 10.0mmol/L
 Hypoglycaemia should be avoided, avoid treatment which lowers the glucose below 5.0mmol/L
 Insulin therapy should allow for tighter targets but this required frequent monitoring and high level
staff training.
What glucose targets should be aimed for in Acute Stroke?
 Patients admitted to hospital with acute thrombotic stroke who have hyperglycaemia , should be
treated to achieve and maintain glucose levels less than 10.0mmol/L
 Hypoglycaemia should be avoided, avoid treatment which lowers the glucose below 5.0mmol/L
What are the appropriate targets for patients in general hospital wards?
 Patients in general hospital wards with hyperglycaemia , should be treated to achieve and maintain
glucose levels less than 10.0mmol/L
 Hypoglycaemia should be avoided, avoid treatment which lowers the glucose below 5.0mmol/L
 To achieve tighter control safely, frequent glucose monitoring is required
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Q. How should HYPERGLYCAEMIA in hospital be prevented and treated?
Treatment of hyperglycaemia in hospitalised patients depends upon the type of diabetes, the patient's
current blood glucose levels, prior treatment, the clinically assessed severity of illness, and the expected
caloric intake during the acute episode.
At the time of admission or before an outpatient procedure or treatment, blood glucose should be
measured and the result known. In addition, glucose monitoring should be continued so that appropriate
action may be taken. The frequency of measurement depends upon the patients' status, the results of
earlier measurements, and the steps taken as a result of those measurements.
Insulin administration
Although most patients with diabetes will have type 2 diabetes, many will require insulin therapy, if only
temporarily during inpatient admissions. In such patients, insulin may be given subcutaneously with or as
an intravenous infusion. The key point is that the patient should have at least a small amount of insulin
circulating at all times, which will significantly increase the likelihood of controlling blood glucose levels
during illness.
Oral diabetes medications or pre-mixed insulin (sub-cutaneous)
These treatment regimens can be used in certain stable hospitalised patients who are eating regularly.
“Basal-bolus" regimen (sub-cutaneous)
Insulin therapy in hospitalised patients should consist of an intermediate-acting insulin, such as NPH, or a
long-acting insulin, such as glargine or detemir, combined with pre-meal rapid or short-acting insulin in
patients who are eating regular meals.
Insulin infusion (intravenous)
Patients with type 1 or type 2 diabetes admitted to the general medical wards can be treated with
subcutaneous insulin. However, many practitioners institute intravenous insulin therapy for patients with
Type 1 diabetes, especially those undergoing long and difficult surgery, or those who will be expected to
have significantly curtailed oral nutritional intake for several days post-operatively, because changes of
dose have a more immediate effect compared with subcutaneous therapy.
The safe implementation of insulin infusion protocols requires frequent monitoring of blood glucose, which
is not typically available on a general medical ward. Practical considerations including skill and availability of
the nursing staff may impact the choice of delivery.
Q. Why is it important to control blood glucose levels when planning a procedure or surgery?
A review of diabetes management prior to surgery or procedure should have been conducted with the
patient’s GP, diabetes specialist, and/or diabetes team or while attention a pre-admission clinic. Ideally,
diabetes should well controlled before the surgery to lessen the chance of complications during and after
operation or procedure.
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Q. What is the concern if blood glucose levels are high before surgery?
Excessive glucose levels slow the healing process and boost the risk of infection. Complications may include
high blood glucose levels, low blood glucose levels, poor wound healing, infection, electrolyte imbalance
and diabetic ketoacidosis (DKA).
Q. What are ketones?
DKA is a potentially fatal condition which arises when there is insufficient insulin to meet need. Ketones are
a by-product of this process. DKA predominantly occurs in patients with yype 1 diabetes but may also be
seen in other forms or diabetes. The most common precipitant for DKA is insulin omission in existing type 1
diabetes, new onset type 1 diabetes and sepsis.
DKA should be suspected in any patient with type1 diabetes presenting with severe hyperglycaemia,
tachypnoea, abdominal pain, vomiting, reduced level of consciousness or fever. Patients admitted with
DKA should be referred to the Diabetes Nurse Educator for review of sick day management, re motivation,
and education prior to discharge. In addition, follow up with a diabetes specialist on discharge is
recommended.
Refer to HNELHD Guidelines for the Management of Diabetic Keto-Acidosis - HNELHD CG 12_12
Q. How do you test for ketones?
Test for ketones if BGL > 15.0mmol/L and/or signs of illness present. Ketone levels can be tested in both
blood and urine. Point of care ketone testing can be done using a capillary blood sample in an Abbott
Freestyle Optium Blood Glucose Monitoring System™. Urinary ketones can be tested with Ketodiastix ™
Medical attention is required if blood ketones remain >1.5 mmol/L despite 2 supplemental insulin doses
and/or if urinary ketones are moderate to heavy (level as indicated on the test strip instructions), and also
not decreasing with supplemental insulin.
Ketone levels should continue to be monitored more frequently if symptoms indicate risk or if tested levels
are raised.
Q. How is steroid-induced diabetes best managed?
Hyperglycaemia is common among patients on steroid medication (particular glucocorticoids). Those
patients without an existing diagnosis of diabetes should be screened for hyperglycaemia by random blood
glucose testing. Hyperglycaemia is best managed with insulin – this could be a pre-mixed insulin (eg.
Mixtard 30/70) or a basal bolus regimen.
Patients who are already on insulin for diagnosed diabetes may require an increased insulin doses
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Q. What is a “Hypo” (low blood glucose level)?
Hypoglycaemia or low blood glucose level (BGL) defined as less than 4 mmol/L. The goals of treatment for
hypos are to use an intervention that provides the fastest rise of the blood glucose to a safe level, to
eliminate the risk of injury and to relieve symptoms quickly. It is important to avoid over-treatment, as this
can result in rebound hyperglycaemia. Clinical staff in health care facilities must be alert in detecting,
treating and preventing hypoglycaemia in patients with diabetes.
Patients with diabetes who are treated with insulin and/or oral diabetes medications that stimulate insulin
production can suffer from hypoglycaemia (low blood glucose) and treatment should commence when BGL
is < 4 mmol/L. Patients treated with diet alone are unlikely to suffer from hypoglycaemia.
For pregnant women who are on insulin therapy, the level at which treatment for hypoglycaemia should be
commenced is < 3.5 mmol/L.
Q. What are the Signs and Symptoms of Hypoglycaemia?
Neurogenic (Autonomic): Trembling, palpitations or tachycardia, sweating, anxiety, hunger, nausea, tingling
around mouth and pallor
Neuroglycopenic: Difficulty in concentration, confusion, weakness, drowsiness, visual disturbance,
difficulty speaking, headache, dizziness, tiredness, change in affect (e.g. argumentative depressed, angry),
coma and convulsions
Q. What is the treatment for a hypo - The “15” Rule
Follow the instructions below to treat a hypo, using the “15” Rule:
1.
Test blood glucose
2.
If level is 4 mmol/L or less
Treat with 15 grams of high GI food/drink: eg.7 small or 5 large jelly beans, ⅓ bottle Lucozade™ or glucose
tablets (take number according to package)
3.
Wait 15 minute and then retest
4.
If level still 4mmol/L or less OR If level is now greater than 4mmol/L
Treat again with 15 grams of
high GI carbohydrate food/drink
(see high GI food/drink above)
Treat with 15 grams of
low GI carbohydrate food/drink
OR
have a meal/snack which contains
exchange of low GI foods:
a. Milk or milk product, yoghurt, ice cream
b. Fruits or fruit juice eg. apple, orange
c. Multi-grain bread
If unconscious do not give liquids or solids, call the ambulance or give Glucagon (Glucagen)
Refer to HNELHD Guidelines for the Management of Hypoglycaemia - HNELHD CG 13_03
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Q. A patient complains of feeling hypo (low) on insulin with a BGL of 7.0mmol/L
This usually means that the body has up-regulated and indicates the glycaemic control is elevated. This
does not require immediate treatment for hypoglycaemia (low BGL), as it is within the normal range. Their
BGL should continue to be monitored as usual.
Q. Who needs to know about glucagon injections?
Some people can’t feel when they are having a hypo and may go unconscious. Glucagon is a hormone that
can be given as an injection and can be given by ambulance officers, family members or nurses. If a patient
has had an unconscious hypo in the past or are at risk of severe hypo they can keep a glucagon kit at home.
Their family, if potentially competent, should be trained in its use by a diabetes educator.
Refer to the Administration of Glucagon for Treatment of Severe Hypoglycaemia MSO 13_01
Q. Who should the patients see regarding their diabetes while an inpatient?
A team approach can decrease the patient's length of stay as well as decrease the total cost of care. Using
the hospitalisation to enhance the patient's knowledge about the diabetes and to improve selfmanagement is encouraged. Referral to a diabetes specialist team, including a diabetes educator, a
dietitian and medical specialists during hospitalisation may be recommended. A consultation with a
diabetes specialist or endocrinologist or health professional who can provide patient education and
nutritional advice is ideal. Patients can be referred to the Diabetes Service for education or medical
management after discharge by faxing a referral to RIMS on Fax number 49223895.
Q. If a patient is on an insulin pump, (continuous subcutaneous infusion CSII) what do I need to watch out
for?
Insulin pumps use only rapid acting insulin analogues and once the pump is disconnected the patient has
little or no insulin on board. Lack of insulin can lead to the development of hyperglycaemia and raised
ketone levels and to DKA. For this reason, it is important that the pump is not disconnected for more than
60 mins without administering insulin by an alternative route (e.g. IV infusion or subcutaneous injection).
Orders for an alternative method of insulin delivery must be charted prior to disconnection of pump. An
insulin pump is operated by the patient, and worn 24 hours a day but may be disconnected for short
periods of up to 1 hour e.g. for showering, exercise or short clinical procedures.
Q. How does an insulin pump (subcutaneous) deliver daily insulin requirements?
An insulin pump will deliver a continuous subcutaneous infusion of insulin to patients with type 1 diabetes.
The device delivers rapid acting insulin in two ways:
1) The basal rate (background insulin) – continuous delivery of small amounts of rapid acting analogue
insulin
2) Bolus doses – delivery of a dose of rapid acting analogue insulin at the time of carbohydrate
consumption, or to correct blood glucose levels above target.
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Q. Who is the best person to manage an insulin pump?
In general an insulin pump should be continued in hospital where the patient can competently and safely
manage the insulin pump and self-dosing. Details of insulin pump therapy should be documented and
supported by the diabetes team.
Insulin pump therapy can be continued for short operative procedures if those responsible for the patients’
intra operative care are comfortable with its use and if it is safe to do so.
Refer to Clinical Guideline Use of Patient Controlled Insulin Pumps in Hospital – to be endorsed by the
Diabetes Clinical Stream
Q. What should happen with their usual diabetes medication while an inpatient?
The type or dose of their usual medication for diabetes may need to be changed due to interaction with
new medications prescribed for other conditions during their hospital stay. The effect of interaction of
other medications on blood glucose levels may depend on many factors, which include whether or not a
patient is taken off normally used medications for some period during hospitalisation. The hospital
pharmacist is responsible for the supply of prescribing medications, noting potential drug interactions.
Q. How will anaesthesia and surgery preparation affect the blood glucose levels?
Patients with diabetes are often taken off their glucose control medications prior to surgery. Patients with
diabetes may also be required to fast before surgery or a procedure. Patients with diabetes are often
scheduled for early morning surgery/procedures to limit the time they are off their medications. The plan is
to return to usual medication regimen as soon as possible.
Patients with diabetes undergoing planned admissions/ procedures should have a pre-operative plan which
considers their medication and diabetes management.
Refer to the Perioperative Diabetes Management guideline - under development
Q. Who should be self-blood glucose monitoring?
Keeping track of blood glucose levels and medication dosages can assist in better diabetes management. All
patients with diabetes using insulin therapy are encouraged to perform blood glucose meters using
portable capillary blood glucose meters. The rapid results using these meters can facilitate the subsequent
making of therapeutic decision which can improve diabetes management and conceivably shorten hospital
inpatient service.
Patients will need to have a NDSS (National Diabetes Support Scheme) registration card to obtain
subsidised supplies for use with the blood glucose meter. If a patient is not registered with the NDSS the
form needs to be completed by/for the patient and signed by a doctor or credentialed Diabetes Educator to
sign and fax to Australian Diabetes Council at Newcastle on 49270474.
Individuals require instruction on use of blood glucose meters required by health professionals who are
competent in the use of meter.
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Q. When is the best time for the patient test their BGLs?
Fasting, pre-prandial and post-prandial BGL testing is recommended, but the number of tests per day will
vary according to their diabetes treatment plan. The testing frequency and timing prior to admission may
be continued for patients who are stable or where tight control is not an aim. The testing schedule may
need to be intensified for patients where tighter glycaemic control is desired, particularly for patients on
insulin, and for patients who are unwell and/or who have medication changes. It is important for testing to
occur both before and after meals to facilitate appropriate adjustments to the patients’’ insulin dose and
monitor for hypoglycaemia. Additional testing at bedtime and during the night may be recommended.
Suggested times to establish a pattern of BGLs as a basis for treatment:
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Fasting - before breakfast
Before a meal (pre-prandial)
2 hours after a meal (post prandial)
Before bed
During the night, if hypos suspected or known to be occurring
Q. What are the targets for glycaemic control in type 2 diabetes?
The normal glycaemia range is 4.0 to 6.0mmol/L pre-prandial, and 4.0 to 7.7 mmol/L post-prandial, but the
NHMRC guidelines accept 6.1 to 8.0mmol/L pre-prandial and 6.0 to 10.0 mmol/L post-prandial as
acceptable ranges.
If BGLs are consistently outside this target range, their treatment regimen should be reviewed.
Long term glycaemic control is monitored by measuring glycosylated haemoglobin (measured as HbA1c),
with a general target of < 53 mmol/mol (or 7.0%).
Tight control in the elderly can result in severe hypoglycaemia and increase falls risk, so the recommended
targets can be tempered by clinical judgement.
Q. What equipment do you need to do a blood glucose test?
The goal is to have patient’s BGLs measured accurately, safely and with adherence to infection control
guidelines and WH&S legislative requirements, resulting in minimal risk of injury to patients and staff.
Awareness of correct manual handling techniques, avoiding stooping, bending and twisting, is the
responsibility of the clinician.
Equipment Requirements
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Blood Glucose Meter (Abbott Australasia has the current supply contract to provide these devices
for HNE Health facilities). Some facilities may still be using a non-health service contracted meter,
and the manufacturer’s instructions for use should be followed.
Test strip – compatible to the monitor to be used. Check for expiry date.
Single use lancet: New Unistik® 2 or Accuchek Safe-T-Pro Plus blood lancet devices. To minimise the
risk of a sharps injury, staff are only to use the Unistik® 2 or Accuchek Safe-T-Pro Plus lancet
devices, as these are single use only and the needle retracts.
Personal Protective Equipment - safety eyewear, gloves.
Alcohol wipes to clean equipment pre and post measurement.
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Gauze squares or cotton balls.
Sharps container.
Contaminated waste bin.
If the machine is malfunctioning or not working, report to NUM or Line Manager for appropriate action.
Refer to BLOOD GLUCOSE MONITORING DEVICE – Use of District-wide Clinical Guideline- to be endorsed by
the Diabetes Stream
Q. What do I need to know about administering insulin?
Sometimes insulin is given to a hospitalised patient with type 2 diabetes to temporarily control blood
glucose levels when usual medication, diet and lifestyle regimens are disrupted.
Insulin may be administered through an insulin drip or infusion, or medical/nursing staff may give insulin
through a subcutaneous injection.
There are many different types of injectable insulin devices available. They may include syringes, disposal
pen devices and pen devices with cartridges.
All patients should receive instruction and education about injectable insulin devices.
Pen devices and cartridges are single use and one person use only, and should never be shared due to the
risk of cross contamination, even if a new pen needle is used for each injection.
Q. What education does a patient need when starting insulin therapy in hospital?
The patient needs information about the following:
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Action of the insulin
How, when and where to inject
How the injectable insulin device works
Needle size and selection
Need to have carbohydrates at each of 3 main meals and reduce calories if type 2
Hypoglycaemia
Complete an NDSS (National Diabetes Support Scheme) form for people starting insulin – a new
NDSS form must be completed when they commence insulin therapy, even if the patient is already
registered with the NDSS, in order to be eligible for the subsidised needles and lancet. They will
continue to receive subsidies for blood glucose monitor test strips.
The need to monitor BGL before driving and not to drive under 5.0mmol/L
See Survival Guide: Starting Insulin Checklist
Q. What size needles should the patient use?
Shorter length needles 4, 5 and 6mm, are generally recommended for both children and adults, including
obese patients, and have been shown to provide equivalent glycaemic control as the longer needles of 8
and 12.7mm length.
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Q. What time should the patient give their insulin?
It is important to understand the action of the insulin. Onset, peak time and duration will vary between
different insulins.
Intermediate or long acting insulin should be administered once daily, at the same time of day. This
includes Protophane, Humulin NPH, Levemir and Lantus. If a twice daily injection regime, then the
injections should be approximately 12 hours apart.
Q. How long before meals should patients have their insulin?
This depends on the type of insulin they are prescribed:
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Short acting human insulin (Actrapid or Humulin R): 30 mins before meals
Rapid acting analogues (Apidra, Novorapid or Humalog): 15 mins before meals
Pre-mixed insulin (Mixtard 30/70, Humulin 30/70 or Mixtard 50/50): 30 mins before meals
Pre-mixed insulin (Novomix or 30 Humalog Mix 25): 15 mins before meals
Q. When do patients require supper?
If BGL is 7.0mmol/L or less supper is recommended.
Q. What must the patient know and have the skills to do before leaving hospital?
If existing diabetes, but new to insulin therapy:
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Update diabetes management
Healthy eating principles (Seen by Dietitian preferable ) OR handout provided
Ensure aware of ‘Hypo management’ and provide handout
Discuss ‘Importance of physical activity’
If newly diagnosed and on insulin therapy
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Discuss ‘What is diabetes – importance of diagnosis ‘
Ensure aware of ‘Hypo management’ and provide handout
Cover ‘Healthy eating principles’ (Seen by Dietitian preferable) OR provide handout
Discuss ‘Importance of physical activity’
If newly diagnosed and on oral diabetes medication:
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Discuss ‘What is diabetes – importance of diagnosis ‘
Discuss ‘How the oral medication works’
Ensure aware of ‘Hypo management’ and provide handout
Cover ‘Healthy eating principles’ (Seen by Dietitian preferable) OR provide handout
Discuss ‘Importance of physical activity’
Assess ability and need to self-monitor blood glucose levels, and if indicated provide inpatient
education
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Q. What has to be organised for the patient prior to their discharge?
If the patient is on insulin:
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Complete NDSS (National Diabetes Support Scheme) application and arrange for doctor or credentialed
Diabetes Educator to sign and fax to Australian Diabetes Council at Newcastle on 49270474
Give Commencing Insulin discharge package
Provide adequate supplies advise how to obtain when home
Arrange relevant appointments
If the patient is taking oral diabetes medication and/or their diabetes is controlled by diet

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Complete NDSS application and arrange for doctor or credentialed Diabetes Educator to sign and fax to
Australian Diabetes Council at Newcastle on 49270474
Give Newly Diagnosed discharge package
Arrange relevant appointments
References:
ADS Guidelines for Routine Glucose Control in Hospital 2013
http://www.diabetessociety.com.au/position-statements.asp
ADEA Guidelines:
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Clinical recommendations for Subcutaneous Injection Technique for Insulin an d Glucagon-like
Peptide 1 2011
ADEA Guidelines for sick day management for people with diabetes 2006
ADEA Guidelines for the Management and Care of Diabetes in the Elderly
http://www.adea.com.au/about-us/our-publications/
RACGP Diabetes Management in General Practice Guidelines for type 2 Diabetes 2012/13
HNE Health intranet Policies Procedures and Guidelines website
http://intranet.hne.health.nsw.gov.au/ppg
NDSS – National Diabetes Services Scheme
http://www.australiandiabetescouncil.com/ndss
Health Pathways provides information about referral to Diabetes Services and about diabetes management.
http://www.hne.healthpathways.org.au
Logon: hnehealth Password: p1thw1ys
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