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Keywords:

  • Nurse practitioners;
  • treatment guidelines;
  • diabetes;
  • diabetes type 1;
  • diabetes type 2;
  • hospital

Abstract

  1. Top of page
  2. Abstract
  3. Scope of the problem
  4. Definition of hyperglycemia
  5. Impact of hyperglycemia on patient outcomes
  6. Management issues
  7. Known risk factors
  8. Recommendations for diabetes care providers
  9. Recommendations for discharge planning
  10. Conclusions
  11. References

Purpose: To provide nurse practitioners (NPs) with a review of the 2012 Standards of Care for the management of hospitalized patients who are hyperglycemic.

Data sources: The 2012 American Diabetes Association's (ADA) Standards of Care for the treatment of inpatient hyperglycemia and selected evidence-based articles.

Conclusions: Because hyperglycemia occurs at alarming rates in the inpatient setting when hyperglycemia is not controlled, there is a great impact on acute and even chronic conditions. These complications will lead to increased healthcare costs.

Implications for practice: It is essential that NPs who care for hospitalized, hyperglycemic patients are aware of the 2012 ADA Standards of Care.

To obtain CE credit for this activity, go to http://www.aanp.org and click on the CE Center. Locate the listing for this article and complete the post-test. Follow the instructions to print your CE certificate.

Disclosure The authors report no competing interests.

Diabetes mellitus is one of the most costly chronic diseases nationwide with inpatient care cost approaching $40 billion per year (Patel & Doughty, 2008). Recently, medical science witnessed new treatments and protocols for a wide spectrum of illnesses. However, little has changed with regard to the urgency for the improvement in inpatient needs for euglycemia from 2011 to 2012. Hyperglycemia remains a very distinct problem in the inpatient population (Moghissi et al., 2009). Hence, the Diabetes Care journal includes recommendations each year on the management of this special population of patients. The recommendations are based on the American Diabetes Association (ADA) and American Association of Clinical Endocrinologists (AACE) consensus statement on glycemic control. These organizations find it necessary to establish, publish, and revisit recommendations for inpatient hyperglycemic treatment on an annual basis. The purpose of this article is to update nurse practitioners (NPs) on the changes in the 2012 Standards of Care for management of hyperglycemia in hospitalized patients.

Scope of the problem

  1. Top of page
  2. Abstract
  3. Scope of the problem
  4. Definition of hyperglycemia
  5. Impact of hyperglycemia on patient outcomes
  6. Management issues
  7. Known risk factors
  8. Recommendations for diabetes care providers
  9. Recommendations for discharge planning
  10. Conclusions
  11. References

The prevalence of diabetes itself among hospitalized patients is difficult to measure. Many times, diabetes is secondary to the presenting problem that prompted the hospitalization (Moghissi et al., 2009). Therefore, it may not be appropriately identified as a problem at discharge. This in itself accounts for some discrepancy in this particular population of patients. Some studies have revealed that approximately 12–38% of hospitalized patients carry a diagnosis of diabetes (Levetan, Passaro, Jablinski, Kass, & Ratner, 1998; Umpierrez et al., 2002). It is even more difficult to estimate the rate of hyperglycemia in the inpatient population. Most of this discrepancy results from disagreement on the definition of inpatient hyperglycemia. Despite the disagreement with a general diagnosis, hyperglycemia can be thought of in three different realms: hospital-related hyperglycemia, previously unrecognized or undiagnosed diabetes, and a history of known diabetes (ADA, 2012).

Definition of hyperglycemia

  1. Top of page
  2. Abstract
  3. Scope of the problem
  4. Definition of hyperglycemia
  5. Impact of hyperglycemia on patient outcomes
  6. Management issues
  7. Known risk factors
  8. Recommendations for diabetes care providers
  9. Recommendations for discharge planning
  10. Conclusions
  11. References

According to the consensus statement, the 2012 definition of hospital-related hyperglycemia is based on either fasting or random glucose measures. Hospital-related hyperglycemia is recognized as any blood glucose level greater than 140 mg/dL (ADA, 2012). In 2012, the ADA defined unrecognized diabetes as hyperglycemia (same parameters as mentioned above for blood sugars), which occurs during the hospitalization and eventually after discharge meets the diagnostic criteria for diabetes. In 2012, the ADA clarified that a medical history of diabetes included any previously diagnosed diabetes that had been recognized by the primary healthcare provider. Furthermore, an A1C of greater than 6.5%, in the absence of prior history, is indicative of undiagnosed diabetes that was present prior to hospitalization (ADA, 2012). Regardless of the type of hyperglycemia noted in the inpatient setting, any patient exhibiting hyperglycemia will require treatment in order to prevent complications.

Impact of hyperglycemia on patient outcomes

  1. Top of page
  2. Abstract
  3. Scope of the problem
  4. Definition of hyperglycemia
  5. Impact of hyperglycemia on patient outcomes
  6. Management issues
  7. Known risk factors
  8. Recommendations for diabetes care providers
  9. Recommendations for discharge planning
  10. Conclusions
  11. References

Within the inpatient setting, patients experiencing hyperglycemia have been shown to have increased rates of infection, length of stay, complications, morbidity, and mortality (Breithaupt, 2010; Frisch et al., 2010; Giakoumidakis, Nenedikis, & Brokalaki, 2012; Newton & Young, 2006; Menzin et al., 2010). Given the discord within the literature, it is difficult for the NP to discern exactly how tight the glycemic control should be. As controversial as it has been, there is a much evidence in support of, as there is against tight glycemic control. The critical issue, therefore, is the ability to find adequate balance on the gradient of glycemia, so that severe hypoglycemia is not experienced, which would subsequently increase the risk of mortality (Crockett, 2009; Moghissi et al., 2009; Reider, Donihl, & Korytkowski, 2009).

Setting

Van den Berghe et al. (2001) specifically investigated intensive glycemic control, defined as blood glucose levels ranging from 80 to 110 mg/dL, in patients in a surgical intensive care unit (SICU) setting that were critically ill. In this study, for every 20 mg over 100 mg/dL, mortality increased 30%. The intensive glycemic control group had marked reductions in mortality (4.6–8.0%), multiorgan failure (34%), systemic infection/sepsis (40%), acute renal failure (41%), and required blood transfusions (50%); the authors concluded that these findings supported the implementation of tight glycemic control (Van den Berghe et al., 2001). Severe hypoglycemia (blood glucose levels less than 40 mg/dL) did occur more frequently in the intensive glycemic control group (5%), as opposed to the control group (0.78%); however, increased mortality was not clearly indicated as a direct result of the severe hypoglycemic episodes for patients in the SICU.

In contrast, when Van den Berghe et al. (2006) replicated this study in a medical ICU (MICU) setting, the findings were vastly different, and more importantly, severe hypoglycemia was found to be a predictor of increased mortality. Comparable evidence was noted in 523 MICU patients with admission blood glucose levels of 110 mg/dL (Arabi, Tamim, & Rishu, 2009). According to Arabi et al. (2009), there was a significant increase of hypoglycemia in the intensive insulin therapy group and increased mortality was strongly associated with severe hypoglycemia. Recent evidence from the NICE-SUGAR study, a large international study of 6104 critically ill patients admitted to both SICU and MICU. With a length of stay greater than 3 days, revealed contrasting evidence regarding detectable differences by ICU settings. When comparing the intensive control group (81–108 mg/dL) to conventional management (a target of 180 mg/dL or less), increased mortality was noted in the intensive control group, with no observable differences in patients regardless of ICU setting (Finfer et al., 2009). Other studies have shown equitable safety concerns associated with intensive control, such as the Glucontrol Trial, or no overall benefit in this type of regimen (Preiser et al., 2009). The Glucontrol Trial was a randomized, single-blinded study with an intensive control group (80–110 mg/dL) and conventional therapy group (140–180 mg/dL). Again, increased risk of severe hypoglycemia (≤ 40 mg/dL) occurred more frequently in the intensive control group with no apparent benefit; moreover, there were no significant differences in all-cause mortality and length of stay (Preiser et al., 2009). Given the ambiguity of the evidence related to setting specific differences (MICU vs. SICU) and intensive glycemic control, NPs should critically review the evidence relevant to their practice settings and populations and consider the confounding effect of nutritional status, end-of-life stage, and pre-existing chronic disease processes within ICU settings to explain the observed differences in the aforementioned studies (Arabi et al., 2009; Finfer et al., 2009; Mesotten & Van den Berghe, 2009; Van den Berghe et al., 2001, 2006; Zander, Boldt, Engelmann, Mertzluff, Sirtl, & Stuttmann, 2007).

Wound infections

NPs should also understand the impact that untreated hyperglycemia has on wound development and overall mortality in the inpatient setting. The risk of wound infection and overall mortality is vitally important to postoperative cardiac patients, more specifically, the healing of sternal wounds (Breithaupt, 2010; Giakoumidakis et al., 2012). The hyperglycemic state unfortunately alters leukocyte function by impairing phagocytosis and hinders the ability to kill bacteria. These alterations in phagocyte function lead to postoperative infections observed in not only cardiac patients, but individuals undergoing general surgery and orthopedic procedures (Breithaupt, 2010). According to Marchant, Viens, Cook, Vail, and Bolognesi (2009), individuals with uncontrolled diabetes had a significantly higher incidence of surgical and systemic complications as well as increased mortality and length of stay following total joint arthroplasy. Furnary, Zerr, Grunkemeier, and Starr (1999) investigated the incidence of deep sternal wound infection after open heart surgery. There were two methods of treatment in this study. The group receiving continuous intravenous infusion of insulin experienced deep sternal wounds 0.8% of the observed time, in comparison to the subcutaneous insulin injection group, at a rate of 2.0%. In addition, those receiving continuous intravenous infusion of insulin during the first 3 days postoperatively had a 50% risk-adjusted mortality rate, which reduced postoperative morbidity and mortality in patients with diabetes undergoing open heart surgery. Another study of 4864 patients with diabetes receiving open heart surgery revealed a 3-day regimen of postoperative continuous intravenous infusion of insulin dramatically decreased the risk of death (57%) and deep sternal wound infections (66%) with target blood glucose levels of ≤ 150 mg/dL (Furnary, Wu, & Bookin, 2004).

Management issues

  1. Top of page
  2. Abstract
  3. Scope of the problem
  4. Definition of hyperglycemia
  5. Impact of hyperglycemia on patient outcomes
  6. Management issues
  7. Known risk factors
  8. Recommendations for diabetes care providers
  9. Recommendations for discharge planning
  10. Conclusions
  11. References

Recent evidence from the AACE and ADA consensus statement concludes that there is a tremendous amount of variability related to the benefit of tight glycemic control; the evidence varies based on the insulin treatment protocol used, glycemic targets, population of interest, and necessary adjustments (Moghissi et al., 2009). Umpierrez et al. (2007) found that basal-bolus insulin regimens such as glargine or glulisine achieve better glycemic control compared to sliding scale insulin in noncritically ill patients diagnosed with type 2 diabetes. Pate and Doughty (2008) supported these findings, noting that in comparison to traditional approaches, such as sliding scale insulin, continuous insulin infusions significantly decreased morbidity and mortality among individuals with diabetes and hyperglycemia associated with metabolic syndrome.

Economic impact

With evolving changes to health care and the current economic climate, it is equally important to consider the financial implications of glycemic control. All of the aforementioned complications, such as infection, have collateral costs associated with them, including wound care, antibiotic use, and increased length of stay. According to Estrada, Young, Nifong, & Chitwood (2003), the length of stay was increased by 0.76 days for every 50 mg/dL increase in blood glucose in cardiac patients with diabetes. The associated cost for these patients approached $3000/day (Newton & Young, 2006). Menzin et al. (2010) evaluated the relationship between glycemic levels and diabetes-related hospitalization and costs. The authors noted that higher A1C levels were associated with increased hospital costs for those who had been hospitalized at least once and with increased use of hospital services related to diabetes. Hence, attention has been focused annually on identifying standards of care for this unique patient population. Accordingly, new standards also recommended point-of-care testing for A1C to provide the opportunity for more timely treatment changes (ADA, 2012).

Known risk factors

  1. Top of page
  2. Abstract
  3. Scope of the problem
  4. Definition of hyperglycemia
  5. Impact of hyperglycemia on patient outcomes
  6. Management issues
  7. Known risk factors
  8. Recommendations for diabetes care providers
  9. Recommendations for discharge planning
  10. Conclusions
  11. References

From 2011 to 2012, only minimal changes have been recommended by the ADA. The recommendations regarding the documentation in the medical record of the history of diabetes have remained unchanged. Similarly, the recommendation for having all patients with diabetes undergo blood glucose monitoring remains unchanged (ADA, 2012). Currently, patients who are not known to have diabetes but have a high likelihood of becoming hyperglycemic are recommended to have an order for glucose monitoring. This includes patients receiving high-dose corticosteroids, enteral or parental nutrition, or those scheduled to receive octreotide or immunosuppressive medications. These factors are known to induce hyperglycemia and therefore, blood glucose monitoring should routinely be ordered. Likewise, if a patient with no known history of diabetes begins displaying hyperglycemia, blood glucose monitoring should be initiated as well.

Recommendations for inpatient blood glucose targets

Controversy continues to surround the target range for hospitalized patients. From 2009 to 2010, several changes related to this goal were made but from 2011 to 2012, the definition has remained unchanged (ADA, 2012). The changes relate to the locale of the patient and then, based on the locale, target ranges for these locales are identified. The 2011 and 2012 guidelines categorize patients into two categories: those who are critically ill and those who are not (ADA, 2012). The glycemic goals for these patients are then dictated by which category they fall into. Critically ill patients should be treated with insulin therapy at a blood sugar of 180 mg/dL (ADA, 2012). Once insulin is initiated the target goal for these patients should be 140–180 mg/dL. Those patients in this category are recommended to have insulin delivered intravenously and with a protocol ensuring safe and effective treatment without a high incidence of hypoglycemia. Noncritically ill patients remain with unclear recommendations for specific target blood glucose ranges. However, if treated with insulin, a preprandial blood glucose of less than 140 mg/dL is recommended and less than 180mg/dL is recommended for randomly tested glucose levels. The 2012 standards also address the importance of individualizing the goals for each patient. The new recommendations focus on the level of glycemic control each individual patient is accustomed to. Basically, if a patient is accustomed to tight control at home, healthcare providers should strive to maintain this control while they are hospitalized. Another aspect to individualizing the care deals with risk for the patient. If the patient is more susceptible to hypoglycemia and has multiple comorbities then it may be best to loosen the control and allow for a higher glucose range. In this case, the risk may outweigh the benefit (ADA, 2012).

Recommendations regarding insulin route

In the hospital, insulin can be delivered via insulin pumps, intravenously and subcutaneously. Scheduled subcutaneous insulin is the current recommendation for noncritically ill patients who display hyperglycemia. Subcutaneous insulin should be ordered using basal, prandial, and supplemental insulin methodology. In accordance with the 2009 guidelines, the current standard discourages the use of sliding scale insulin as a standalone method (ADA, 2012).

For hospitalized patients with hyperglycemia, focus should be placed on treatment with insulin (ADA, 2012). The route typically depends on the severity of illness and locale of the patient. For those who are critically ill and in the ICU, the intravenous route of insulin for therapy is recommended. However, for those who are not critically ill and are not in critical care units, subcutaneous insulin via a basal/bolus method is the preferred treatment. Current guidelines state that oral agents as well as injectable noninsulin agents should have a very limited role in the hospitalized patient (ADA, 2012).

In the ICU setting, intravenous insulin can be a very effective way to manage glycemia. Moreover, the intravenous insulin protocol must ensure effective and yet safe management of hyperglycemia (Bode, Braithwite, Steed, & Davidson, 2004). Well-written and studied protocols can provide a way for bedside nurses to aid the glycemic team with this goal. Eventually, the patient will need the intravenous insulin discontinued. Even though intravenous insulin may not be appropriate anymore, it is still necessary that adequate glycemic control is maintained with subcutaneous insulin. Patients meet criteria to wean off intravenous insulin and bridge to subcutaneous insulin when they: (a) reach therapeutic blood glucose levels; (b) advance to a three-meal-a-day plan; or (c) are ready to transfer to a less acute setting such a bed on a general medical unit. The amount of daily intravenous insulin can be helpful as a baseline in calculating the subcutaneous need by dividing the total daily dose of insulin into basal and mealtime (prandial) insulin (see Table 1). Adjustments in the routine can be made by using a correction scale for blood glucose levels remaining elevated after the use of basal and prandial insulin (see Table 2).

Table 1.  Stepwise approach for subcutaneous weight-based dosing for basal/bolus (prandial) method
  1. Adapted from Braithwaite (2009).

Step 1. WeightWeigh patient in kilograms
Step 2. Calculating the total daily dose of insulin (TDD)TDD = weight in kg × 0.3 units/kg/day (Note: the units/kg/day may range from 0.3 to 1 unit/kg/day)
Step 3. Calculate total basal dose and total prandial doseTDD/2 = total basal dose TDD/2 = Total prandial dose
Step 4. Calculate the prandial dose to be given at each mealTotal prandial dose/3 meals = dose at each meal
Table 2.  Stepwise approach to subcutaneous correction scale insulin calculation (individualized for every patient)
Step 1. Determine the patient's correction factorVery resistant (Requires very high dose)Resistant (Requires high dose)Average (Requires moderate dose)Sensitive (Requires lower dose)
  1. BG, blood glucose; TDD, total daily dose.

Step 2. Find your correction factor1500/TDD = ____mg/dL per 1 unit of insulin (should not make up more than 8–10% of TDD)1800/ TDD = ____ mg/dL per 1 unit of insulin (should not make up more than 8–10% of TDD)2000/TDD = ____ mg/dL per 1 unit of insulin (should not make up more than 8–10% of TDD)2200/ TDD = ____mg/dL per 1 unit of insulin (should not make up more than 8–10% of TDD)
Step 3. Determine dose of correction insulin neededCurrent BG-target BG/correction factorCurrent BG-target BG/correction factorCurrent BG-target BG/correction factorCurrent BG-target BG/correction factor

With patients who are considered noncritical or those in rooms outside the ICU setting, subcutaneous insulin is the preferred method of achieving glycemic control (ADA, 2012). This method is best used for all patients with known diabetes, those with newly noted diabetes, and even those with stress hyperglycemia. Again, the recommendation is to avoid sliding scale insulin as a monotherapy.

Recommendations for the use of noninsulin agents

In the 2010 ADA standards, a new section was designated solely for the discussion of noninsulin agents. Currently, the consensus statement still recommends that it is inappropriate to use noninsulin agents in the hospitalized patient (ADA, 2012). Metformin (glucophage) is strongly discouraged because of the risk of complications that may arise from its use in the inpatient setting. Likewise, the new recommendations advise against the use of injectable noninsulin agents because of a lack of data on the safety of their continuation in the hospital setting.

Recommendations for special clinical situations

There are specific clinical situations that arise in the hospitalized patient that need special attention related to glycemic control. This section includes the use of insulin pumps, enteral and parenteral nutrition, and glucocorticoid therapy as they relate to glucose control. The ADA addresses each clinical situation and provides recommendations for inpatient care in the 2012 standards.

Patients who use insulin pumps should be allowed to continue the use in the hospital as along as they are mentally and physically able (ADA, 2012). The patient must also be able to share each setting and boluses with the staff. It is crucial to have staff familiar with insulin pumps as well.

Patients receiving enteral feedings often develop hyperglycemia. For this reason, it is imperative to treat the hyperglycemia (ADA, 2012). Although the recommendation for the best method of treatment is not mentioned, the need for control of the hyperglycemia is stressed. Similar to enteral nutrition, parenteral nutrition is also noted to cause a high incidence of hyperglycemia, which can increase the incidence of complications. For this reason, it is recommended that the elevated blood glucose levels are treated according to the severity of illness as mentioned previously.

Hyperglycemia is often noted in patients receiving steroid treatment. Thus, it is recommended that these patients also receive insulin therapy, if warranted by their blood glucose levels. One recommendation is to check blood glucose for 48 h after the initiation of such glucocorticoid therapy (ADA, 2012). Then, if needed, order insulin to cover the blood glucose increases. As the steroids are weaned, the insulin dosing should be tapered in order to avoid hypoglycemia.

Recommendations for the treatment of and prevention of hypoglycemia

The recommendations for the treatment for hypoglycemia remain the same as those in the 2011 standards. The fear of hypoglycemia remains as one of the biggest obstacles in the treatment of hyperglycemia. Hospitalized patients receiving insulin may have hypoglycemic episodes because of multiple reasons (ADA, 2012). One such reason may be that the nutritional intake is less than it once was; decreased intake can lead to hypoglycemia unless the regular insulin dose is adjusted. Heart failure, renal failure, liver disease, infection, malignancy, and sepsis can all cause an increased risk of hypoglycemia. Regardless of the reasons, hypoglycemia will remain an obstacle in the treatment of hyperglycemia for inpatients. In order to combat this problem, institutions are encouraged to track hypoglycemic episodes. The use of quality assurance measures can be helpful in identifying common problems and addressing them in an attempt to reduce hypoglycemic episodes.

Recommendations for diabetes care providers

  1. Top of page
  2. Abstract
  3. Scope of the problem
  4. Definition of hyperglycemia
  5. Impact of hyperglycemia on patient outcomes
  6. Management issues
  7. Known risk factors
  8. Recommendations for diabetes care providers
  9. Recommendations for discharge planning
  10. Conclusions
  11. References

Although no new recommendations were discussed with regard to diabetes care providers in the hospital, we believe it is necessary to mention that NPs should be considered in the mix of those providers skilled to care for hospitalized hyperglycemic patients. NPs could provide much insight and continuity of care to the hyperglycemic patient population while reducing costs for the institutions in which they practice. NPs could also be instrumental in the development of a glycemic control teams and provide safe and effective treatment for these particular patients.

Point-of-care monitoring, A1C, self-management, and medical nutrition therapy recommendations

From 2011 to 2012, the ADA made very few changes to the point-of-care, self-management, and medical nutritional therapy. The ADA (2012) currently recommends that blood glucose monitoring be performed before meals and at bedtime in those patients maintaining a three-meal-a-day pattern while in the hospital. Likewise, if the patient is receiving intravenous insulin therapy, the recommendation remains that the blood sugar be monitored anywhere from every 30 min to every 2 h, the frequency being determined by the protocol. An A1C is also still recommended for all patients with known diabetes who do not have a retrievable A1C noted in the last 2–3 months. The ADA did not add any new recommendations to the self-management recommendations in the hospital setting. The medical nutrition therapy section also had no new recommendations.

Recommendations for discharge planning

  1. Top of page
  2. Abstract
  3. Scope of the problem
  4. Definition of hyperglycemia
  5. Impact of hyperglycemia on patient outcomes
  6. Management issues
  7. Known risk factors
  8. Recommendations for diabetes care providers
  9. Recommendations for discharge planning
  10. Conclusions
  11. References

The section discussing discharge planning for patients with hyperglycemia did not change from the previous standards, but several pertinent points are noted here. Before a patient is discharged, specific learning objectives related to diabetes management should be addressed (ADA, 2012). Staff should ensure that patients have (a) adequate knowledge of diabetes itself; (b) an understanding of the importance of blood glucose monitoring as well as how to monitor their blood glucose at home; (c) an understanding of the symptoms of hyperglycemia and hypoglycemia along with prevention methods; (d) an understanding of who will manage their diabetes as an outpatient, (e) facts regarding their medications; (f) details regarding sick day rules; and (g) details regarding the disposal of lancets, needles, or syringes. Before discharge, the patient should have a current prescription for medications (insulin or other diabetic medications), supplies (pen needles/syringes, blood glucose meter, testing strips, a glucagon emergency kit, and a medical alert application). Of course, these are the minimal requirements for meeting discharge plans. An appointment for outpatient teaching should also be made along with a follow-up appointment with the appropriate healthcare provider. The follow-up appointment should be scheduled within 1 month of discharge; however, if the patient is newly diagnosed with diabetes and the follow-up could be sooner and additional teaching required.

Conclusions

  1. Top of page
  2. Abstract
  3. Scope of the problem
  4. Definition of hyperglycemia
  5. Impact of hyperglycemia on patient outcomes
  6. Management issues
  7. Known risk factors
  8. Recommendations for diabetes care providers
  9. Recommendations for discharge planning
  10. Conclusions
  11. References

In summary, hyperglycemia occurs at alarming rates in the inpatient setting (Levetan et al., 1998; Moghissi et al., 2009; Umpierrez et al., 2002). When hyperglycemia is not controlled, there is a great impact on acute and even chronic conditions (Levetan, Passaro, Jablonski, Kass, & Ratner, 1998; Umpierrez et al., 2002). These adverse effects will inevitably lead to an upward spiral in healthcare costs (Moghissi et al., 2009). Therefore, it is necessary that NPs involved in the care of hospitalized patients be aware of the ADA Standards of Care that are revised annually. If NPs adhere to such guidelines, there is potential for the patient to avoid preventable complications associated with uncontrolled inpatient hyperglycemia. Patients may also be positively impacted by direct reduction of costs associated with caring for individuals in an acute care setting.

References

  1. Top of page
  2. Abstract
  3. Scope of the problem
  4. Definition of hyperglycemia
  5. Impact of hyperglycemia on patient outcomes
  6. Management issues
  7. Known risk factors
  8. Recommendations for diabetes care providers
  9. Recommendations for discharge planning
  10. Conclusions
  11. References
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