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Assess and identify at risk patients

(ADA, 2015; CDA, Houlden, Capes, Clement, Miller, 2013)

  1. Elicit any history of diabetes from all patients admitted to hospital.
  2. Clearly identify diagnosis of diabetes on the patient's medical record.

Monitoring blood glucose

(CDA, Houlden, Capes, Clement, Miller, 2013).

  1. Monitor blood glucose on a routine, individualized basis in all patients with diabetes (Rubin & Golden, 2013). Consider performing glucose monitoring before meals and at bedtime in patients who are eating. Consider performing glucose monitoring every four to six hours in patients who are NPO (nothing by mouth) or receiving continuous enteral feeding. Monitor glucose every one to two hours for patients on continuous IV insulin.

Insulin therapy

(ADA, 2015; CDA, Houlden, Capes, Clement, Miller, 2013; IHI, Reduce adverse drug events, 2012; Moghissi et al., 2009; Roberts et al., 2012; Rubin & Golden, 2013)

  1. Patients with type 1 diabetes must be maintained on insulin therapy at all times to prevent diabetic ketoacidosis (DKA).
  2. Use a proactive approach in all patients with diabetes (either type 1 or type 2) being treated with insulin by using basal, bolus and correction (supplemental) doses of insulin.
  3. Avoid use of sliding-scale insulin (SSI) as the sole regimen for the management of hyperglycemia.
  4. Preprandial blood glucose targets should be 5.0 to 8.0 mmol/L in conjunction with random BG values <10.0 mmol/L for the majority of non-critically ill patients who are treated with insulin. When patients are critically ill, blood glucose levels should be maintained between 8.0 and 10.0 mmol/L.
  5. Provided that their medical conditions, dietary intake and glycemic control are acceptable, people with diabetes should be maintained on their pre-hospitalization oral anti-hyperglycemic agents or insulin regimens.
  6. Consider using intravenous insulin for patients who are critically ill, patients who are not eating or those who require prompt improvement in their glycemic control.
  7. Use insulin infusion protocols when administering IV insulin to minimize the risk of hypoglycemia.
  8. Except in the case of hyperglycemic emergencies (e.g. diabetic ketoacidosis, hyperosmolar hyperglycemic state), patients receiving IV insulin should receive some form of glucose (e.g. IV glucose or through total parenteral nutrition or enteral feeding).

Insulin with enteral or parenteral feedings

(CDA, Houlden, Capes, Clement, Miller, 2013)

  1. Consider administration of insulin with the nutrition when insulin is required.
  2. To determine the total daily dose (TDD) of insulin required in enteral or parenteral feeding, consider using an IV infusion of regular insulin.
  3. Consider using subcutaneous correction (supplemental) insulin in addition to the insulin mixed with the parenteral nutrition for unusual hyperglycemia.
  4. Patients with type 1 diabetes must be given subcutaneous insulin if the total parenteral nutrition (TPN) is interrupted to prevent diabetic ketoacidosis.

Peri-operative patients

(CDA, Houlden, Capes, Clement, Miller et al., 2013)

  1. Maintain perioperative glycemic levels between 5.0 and 10.0 mmol/L for most surgical situations.
  2. During surgery, ensure that insulin therapy and glucose monitoring are conducted with an appropriate protocol.
  3. Ensure that perioperative staff has received training in the safe and effective implementation of diabetes therapy.

Patients receiving corticosteroid therapy

(CDA, Houlden, Houlden, Capes, Clement, Miller, 2013).

  1. When patients are receiving corticosteroids in conjunction with insulin therapy, ensure both patient and staff know that when the corticosteroid dose is being tapered the insulin dosage will likely need to be decreased to prevent hypoglycemia.

Patient self-management

(ADA, 2015; CDA, Houlden, Capes, Clement, Miller, 2013)

  1. Consider patient self-management of insulin for select youth and adult patients who are competent, have stable daily insulin requirements, successfully self-manage their diabetes at home, have physical skills to self-administer insulin, are able to perform self-monitoring of blood glucose, have adequate oral intake, are proficient in carbohydrate counting, use multiple daily insulin injections /or insulin pump therapy, and understand sick-day management of insulin therapy.
  2. When patients are self-managing insulin, ensure that adjustments are made to accommodate for differences in meals and activity levels, the effects of illness and the effects of other medications.
  3. For patients on insulin pump therapy, ensure that the hospital has clear policies and procedures in place.

Nutrition therapy

(ADA, 2015; CDA, Houlden, Capes, Clement, Miller, 2013; Curll et al., 2010; Gosmanov et al., 2012)

  1. Ensure that all patients with and without diabetes undergo nutrition assessment on admission with subsequent implementation of physiologically sound caloric support.
  2. For patients with diabetes, ensure the use of a consistent carbohydrate diabetes meal-planning system that is based on the total amount of carbohydrate offered rather than on specific calorie content at each meal.

Organizational actions

(ADA, 2015; CDA, Houlden, Capes, Clement, Miller, 2013)

  1. In hospitalized patients, hypoglycemia should be avoided. Protocols for hypoglycemia avoidance, recognition and management should be implemented with nurse-initiated treatment, including glucagon for severe hypoglycemia when IV access is not readily available. Patients at risk of hypoglycemia should have ready access to an appropriate source of glucose (oral or IV) at all times, particularly when NPO or during diagnostic procedures.
  2. Establish individualized patient plans for preventing and treating hypoglycemia.
  3. Record and track episodes of hypoglycemia in the medical record.
  4. Ensure that there are standardized orders for scheduled and correction-dose insulin.
  5. If not already present, create a multidisciplinary steering committee to provide educational programs, implement policies to assess and monitor the quality of glycemic management, and produce standardized order sets, protocols and algorithms for diabetes care within the institution.
  6. Establish order sets for basal-bolus-supplemental insulin regimens and insulin management algorithms.
  7. Implement and maintain a quality control program to ensure the accuracy of bedside BG Point of Care Testing.
  8. Ensure that there are standardized nurse–initiated treatment protocols to address mild, moderate and severe hypoglycemia.
  9. Ensure there is staff education/awareness on factors that increase the risk of hypoglycaemia; such as sudden reduction in oral intake, discontinuation of PN or enteral nutrition, unexpected transfer from the nursing unit after rapid-acting insulin administration or a reduction in corticosteroid dose.

Transition from hospital to home

(CDA, Houlden, Capes, Clement, Miller, 2013)

  1. Ensure that patients and their family or caregivers receive written and oral instructions regarding their diabetes management at the time of hospital discharge. Ensure that these instructions include recommendations for timing and frequency of home glucose monitoring; identification and management of hypoglycemia; a reconciled medication list, including insulin and other glucose-lowering medication; and identification and contact information for healthcare providers responsible for ongoing diabetes care and adjustment of glucose-lowering medication. Patients and their primary care providers should be aware of the need for potential adjustments in insulin therapy that may accompany adjustments of other medications prescribed at the time of discharge, such as corticosteroids or octreotide.

Non-diabetic hypoglycemic coma and drug-induced hypoglycemia without coma

  1. Monitor blood glucose level after starting patients on drug therapy with Bactrim (sulfamethoxazole and trimethoprim, an antibiotic), beta-blockers, haloperidol, MAO (monoamine oxidase) inhibitors, pentamidine, quinidine, quinine, ACE (angiotensin-converting enzyme) inhibitors, lithium and second generation antipsychotic agents (Cryer, 2011; Desimone & Weinstock, 2016; Murad et al., 2009; Suzuki et al., 2009).
  2. Monitor blood glucose level if patients receive insulin or medications for type 2 diabetes by error.
  3. Monitor blood glucose in patients who are using alcohol.
  4. Monitor blood glucose following bariatric surgery.

Conduct Clinical and System Reviews (see details below)

Given the broad range of potential causes of this clinical group, in addition to recommendations listed above, we recommend conducting clinical and system reviews to identify latent causes and determine appropriate recommendations.

Clinical and System Reviews, Incident Analyses

Occurrences of harm are often complex with many contributing factors. Organizations need to:

  1. Measure and monitor the types and frequency of these occurrences.

  2. Use appropriate analytical methods to understand the contributing factors.

  3. Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.

  4. Have mechanisms in place to mitigate consequences of harm when it occurs.

To develop a more in-depth understanding of the care delivered to patients, chart audits, incident analyses and prospective analyses can be helpful in identifying quality improvement opportunities. Links to key resources for analysis methods are included in Resources for Conducting Incident and/or Prospective Analyses section of the Introduction to the Hospital Harm Improvement Resource.

Chart audits are recommended as a means to develop a more in-depth understanding of the care delivered to patients identified by the HHI. Chart audits help identify quality improvement opportunities.

Useful resources for conducting clinical and system reviews: