Managing Diabetes and Hyperglycemia
Improving Inpatient Care
STATEMENT OF PURPOSE:
This course consists of 7 on-line modules. Participants are asked to complete a
pre-course survey and a post-test.
Module
1
2
3
4
5
6
7
Topic
Hyperglycemia and hospital outcomes
Challenges and opportunities for care improvement
Initial recognition, triaging, and management
Principles of pharmacologic management: Insulin 1
Principles of pharmacologic management: Insulin 2
Review of policies and procedures
Getting patients ready for discharge
OBJECTIVES:
After completing all 7 modules participants will:
1. Discuss the importance of controlling inpatient hyperglycemia;
2. Describe guidelines for recognizing and triaging patients with hyperglycemia;
3. Identify hyperglycemia management techniques.
PREREQUISITES:
None.
MATERIALS NEEDED:
1. Pre-Course Survey
2. PowerPoint Presentation
3. Content Outline
4. Post Test
5. Evaluation
METHOD OF PRESENTATION:
Start with introduction; allow time for the pre-program survey to be completed. Review
objectives, present material, provide time for post-test and evaluation to be completed.
Module 3: Initial Recognition, Triaging, and Management of Hyperglycemia
STATEMENT OF PURPOSE:
Module 3:
Module 3 is intended to provide information about phases of inpatient glucose management, how to
differentiate types of hyperglycemia, and how to initiate appropriate management steps.
Participants will be able to:
1. Describe the phases of inpatient glucose management
2. State the different types of hyperglycemic patients encountered in the hospital setting
3. Discuss how to initiate appropriate management steps according to type of diabetes and severity of
hyperglycemia
PREREQUISITES:
Completion of Modules 1 and 2
MATERIALS NEEDED
1. PowerPoint Presentation
2. Content Outline
3. Post Test
4. Evaluation
CONTENT
Descriptions of phases of glucose management, hyperglycemic patients and initial
management steps
METHOD OF PRESENTATION
Start with introduction. Review objectives, present material, provide time for post test
and evaluation to be completed.
CONTENT OUTLINE
Module 3 Objectives
Phases of Inpatient
Hyperglycemia Care
DETAIL
Module 3 discusses the phases of
inpatient glucose management, the
types of hyperglycemic patients
you will encounter in the hospital,
and how to initiate appropriate
glucose management.
We will conceptually divide
inpatient hyperglycemia care into
three phases after admission.
Phase 1 is the first 24 hours, Phase
2 is continued care, and Phase 3 is
discharge planning. We should
identify hyperglycemia as soon as
possible after admission. As soon
as it is identified we should initiate
the treatment plan.
Ongoing monitoring, education
and treatment adjustment should
be conducted during the continued
care phase.
Discharge planning starts at the
time of admission. In some cases
the general discharge plan will be
evident (such as in the case of a
newly diagnosed Type 1 or Insulin
Requiring Type 2 patient who will
need instruction on insulin use
along with multiple other criteria
during the hospital stay). In other
cases the discharge plan may not
be finalized until close to
discharge but the patient’s
instruction should be initiated as
soon as possible.
Begin thinking about what therapy
you will prescribe for home
glucose management and what
follow-up care you will order.
Evaluate daily the progress your
patient is making in self-care
skills.
INSTRUCTOR’S NOTES
CONTENT OUTLINE
Types of Hyperglycemic
Patients in the Hospital
Minimum Admission
Actions
DETAIL
INSTRUCTOR’S NOTES
There are several types of
hyperglycemic patients in the
hospital. There are patients with
pre-existing diabetes. They have a
history of diabetes and may
already be on pharmacotherapy.
There are patients with
undiagnosed diabetes. Often they
have unequivocal hyperglycemia
(glucose greater than or equal to
200 mg/dL) on admission.
There are also patients with stress
hyperglycemia. This is
hyperglycemia that develops in
response to the acute illness or
medications. These patients
require therapy during hospital
stay if their blood glucose is above
target range for their unit (ICU 80- Insert your hospital’s targets if
110 mg/dL, Med Surg and Peri-Op they are different.
90-140 mg/dL).
Patient with diabetes or
hyperglycemia, or patient who are
at risk of developing
hyperglycemia (For example,
transplant patients, patients
starting steroids, patients
experiencing extreme stress)
should have the following at
admission as a minimum:
 Bedside glucose
monitoring before meals,
bedtime and 3AM if eating
or every 6 hours if not
eating.
 A1C if none available from
past 60 days
 Documentation in
admission note about the
presence or risk of
hyperglycemia
 Therapeutic strategy
outlined
Remember to include the problem
CONTENT OUTLINE
Initial Management
Decisions
Triaging Patient Without
Known Diabetes
DETAIL
of diabetes/hyperglycemia in your
problem list!
Initial management decisions
should be based on the type of
diabetes and severity of
hyperglycemia.
Half of the patients with diabetes
are undiagnosed.
Patients without a known
diagnosis of diabetes but who
exhibit hyperglycemia on
admission are likely to have
diabetes and should be treated as
such.
Upon admission patients may fit
into groups. The first group to
consider is the one including
DKA, Hyperglycemic Crisis, and
Labor and Delivery. Care for
these patients should include:
 Obtaining a recent A1C
 Beginning IV Insulin
Protocol
 Hourly blood glucose
monitoring
Another group would include
patients with no previous Diabetes
diagnosis but their blood glucose
is greater than or equal to 200
mg/dL. Care for these patients
should include:
 Obtaining a recent A1C
 Beginning blood glucose
monitoring
 Correction of any BG
greater than 140 mg/dL
with rapid acting insulin.
This group may be triaged into
further therapy as follows:
Start basal-bolus insulin protocol
and consult the diabetes education
team for patients who experience
INSTRUCTOR’S NOTES
CONTENT OUTLINE
Triaging Patients Without
Known Diabetes
(continued)


DETAIL
two consecutive bedside
glucose results greater than
or equal to 140 mg/dL.
Continue to monitor and
start correction insulin for
patients who occasionally
experience glucose levels
140 to 199 mg/dL.
Consider basal-bolus
insulin in patients such as
cardiac patients.

The third group includes patients
with unequivocal hyperglycemia.
Blood glucose levels are greater
than or equal to 200 mg/dL but
they do not have DKA,
hyperglycemic crisis or labor.
Initial Management for
Patients With Known
Diabetes
Care for these patients should
include:
 Obtaining a recent A1C
 Beginning glucose
monitoring
 Initiation of scheduled
insulin therapy
Remember, all insulin deficient
patients, especially Type 1
diabetes, must have insulin!
First determine if the patient is
insulin requiring. Type 1 or
Insulin Requiring Type w or
Gestational patients should be
considered for this group.
Treatment should include:
 Obtaining recent A1C
 Start blood glucose
monitoring
 Continue and adjust
insulin regimen
Patients with non-insulin requiring
Type 2 diabetes or patients with
diet controlled Gestational
Diabetes would be included in the
other group.
INSTRUCTOR’S NOTES
CONTENT OUTLINE
Case Scenario
DETAIL
If the patient was taking oral
agents prior to admission,
consider discontinuing them at
admission if acutely ill.
 Obtain a recent A1C
 Start blood glucose
monitoring
 Start insulin if needed
Patients with no previous
pharmacotherapy should have
orders for:
 Obtaining a recent A1C
 Blood glucose monitoring
 Initiation of insulin if
needed
A 75 year old, lean, woman, with
a five year history of diabetes is
admitted for elective knee
replacement. She has always
needed insulin to control
hyperglycemia. She is currently
on short acting insulin with meals
and a long acting insulin in the
evening. You place her only on a
sliding scale (correction) insulin
program. Her blood glucoses start
to rise pretty quickly into the
300’s and 400’s, and you
desperately call the Endocrine
service.
What went wrong?
She has Type 1 Diabetes and
needs a basal-bolus insulin
program. Not every person who
develops diabetes in older years
has Type 2 diabetes. Be certain to
correctly classify your patient’s
diabetes and never withhold basal
insulin from someone with Type 1
diabetes.
INSTRUCTOR’S NOTES
CONTENT OUTLINE
When a patient with preexisting diabetes is
admitted to the hospital…
Module Summary
DETAIL
When a patient with pre-existing
diabetes is admitted to the hospital
determine if the patient is insulin
requiring. Type 1 Diabetes
patients ALWAYS need a long
acting (basal) insulin even if they
are fasting. They also need meal
bolus insulin based on the
carbohydrate they consume at
each meal.
If patients are already on
outpatient insulin, chances are
they were on it because they
needed it. At the very least keep
them on basal insulin until you are
sure they don’t need it.
1. Hyperglycemic inpatients are
diverse.
2. Be sure you know who you are
managing.
3. Identify hyperglycemic
patients early.
4. Apply appropriate therapy
early.
INSTRUCTOR’S NOTES