1、16. Diabetes Care in the Hospital:Standards of Medical Care inDiabetes2022Diabetes Care 2022;45(Suppl. 1):S244S253 | https:/doi.org/10.2337/dc22-S016American Diabetes AssociationProfessional Practice Committee*The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes”includes th
2、e ADAs current clinical practice recommendations and is intended to pro-vide the components of diabetes care, general treatment goals and guidelines, andtools to evaluate quality of care. Members of the ADA Professional Practice Commit-tee, a multidisciplinary expert committee (https:/doi.org/10.233
3、7/dc22-SPPC), areresponsible for updating the Standards of Care annually, or more frequently as war-ranted. Fora detailed description of ADA standards, statements, and reports, as wellas the evidence-grading system for ADAs clinical practice recommendations, pleaserefer to the Standards of Care Intr
4、oduction (https:/doi.org/10.2337/dc22-SINT).Readers who wish to comment on the Standards of Care are invited to do so atprofessional.diabetes.org/SOC.Among hospitalized patients, hyperglycemia, hypoglycemia, and glucose variabilityare associated with adverse outcomes, including death (13). Therefore
5、, carefulmanagement of inpatients with diabetes has direct and immediate benefits. Hospi-tal management of diabetes is facilitated by preadmission treatment of hyperglyce-mia in patients having elective procedures, a dedicated inpatient diabetes serviceapplying well-developed standards, and careful
6、transition out of the hospital toprearranged outpatient management. These steps can shorten hospital stays andreduce the need for readmission, as well as improve patient outcomes. Some in-depth reviews of hospital care for patients with diabetes have been published(35). For older hospitalized patien
7、ts or for patients in the long-term care facilities,please see Section 13, “Older Adults” (https:/doi.org/10.2337/dc22-S013).HOSPITAL CARE DELIVERY STANDARDSRecommendations16.1 Perform an A1C test on all patients with diabetes or hyperglycemia(blood glucose 140 mg/dL 7.8 mmol/L) admitted to the hosp
8、ital ifnot performed in the prior 3 months. B16.2 Insulin should be administered using validated written or computerizedprotocols that allow for predefined adjustments in the insulin dosagebased on glycemic fluctuations. BConsiderations on AdmissionHigh-quality hospital care for diabetes requires st
9、andards for care delivery,which are best implemented using structured order sets, and quality assur-ance for process improvement. Unfortunately, “best practice” protocols,reviews, and guidelines (24) are inconsistently implemented within hospitals.To correct this, medical centers striving for optima
10、l inpatient diabetes treat-ment should establish protocols and structured order sets, which include com-puterized physician order entry (CPOE).*A complete list of members of the AmericanDiabetes Association Professional Practice Com-mittee can be found at https:/doi.org/10.2337/dc22-SPPC.Suggested c
11、itation: American Diabetes Asso-ciation Professional Practice Committee. 16.Diabetes care in the hospital: Standards ofMedical Care in Diabetes2022. Diabetes Care2022;45(Suppl. 1):S244S253 2021 by the American Diabetes Association.Readers may use this article as long as thework is properly cited, th
12、e use is educationaland not for profit, and the work is not altered.Moreinformationisavailableathttps:/diabetesjournals.org/journals/pages/license.16. DIABETES CARE IN THE HOSPITALS244Diabetes Care Volume 45, Supplement 1, January 2022Downloaded from http:/diabetesjournals.org/care/article-pdf/45/Su
13、pplement_1/S244/636895/dc22s016.pdf by guest on 10 July 2022Initial orders should state the type ofdiabetes (i.e., type 1, type 2, gestationaldiabetes mellitus, pancreatic diabetes)when it is known. Because inpatienttreatment and discharge planning aremore effective if based on preadmissionglycemia,
14、 an A1C should be measuredfor all patients with diabetes or hypergly-cemia admitted to the hospital if the testhas not been performed in the previous3 months (69). In addition, diabetesself-management knowledge and behav-iors should be assessed on admissionand diabetes self-management educationprovi
15、ded, if appropriate. Diabetes self-management education should includeappropriate skills needed after discharge,such as medication dosing and adminis-tration, glucose monitoring, and recogni-tion and treatment of hypoglycemia(2,3).There is evidence to support pread-mission treatment of hyperglycemia
16、 inpatients scheduled for elective surgeryasaneffectivemeansofreducingadverse outcomes (1013).The National Academy of Medicinerecommends CPOE to prevent medica-tion-related errors and to increase effi-ciencyinmedicationadministration(14). A Cochrane review of randomizedcontrolledtrialsusingcomputeri
17、zedadvice to improve glucose control in thehospital found significant improvementin the percentage of time patientsspent in the target glucose range,lower mean blood glucose levels, andnoincreaseinhypoglycemia(15).Thus, where feasible, there should bestructured order sets thatprovidecomputerized adv
18、ice for glucose con-trol. Electronic insulin order templatesalsoimprovemeanglucoselevelswithout increasing hypoglycemia inpatients with type2 diabetes, sostructured insulin order sets should beincorporated into the CPOE (16,17).Diabetes Care Providers in theHospitalRecommendation16.3 When caring for
19、 hospitalizedpatients with diabetes, con-sult with a specialized diabe-tesor glucose managementteam when possible. CAppropriately trained specialists orspecialty teams may reduce the lengthof stay, improve glycemic control, andimprove outcomes (10,18,19). In addi-tion, the greater risk of 30-day rea
20、dmis-sion following hospitalization that hasbeen attributed to diabetes can bereduced and costs saved when inpatientcare is provided by a specialized diabe-tes management team (20,21). In across-sectional comparison of usual caretomanagementbyspecialistswhoreviewed cases and made recommenda-tions so
21、lely through the electronic med-ical record, rates of both hyper- andhypoglycemia were reduced 3040% byelectronic “virtual care” (22). Details ofteam formation are available in theJoint Commission standards for pro-grams and from the Society of HospitalMedicine (23,24).Even the best orders may not b
22、e car-ried out in a way that improves quality,nor are they automatically updatedwhen new evidence arises. To this end,the Joint Commission has an accredita-tion program for the hospital care ofdiabetes (23), and the Society of Hospi-tal Medicine has a workbook for pro-gram development (24).GLYCEMIC
23、TARGETS INHOSPITALIZED PATIENTSRecommendations16.4 Insulin therapy should be initi-ated for treatment of persistenthyperglycemiastartingatathreshold $180 mg/dL (10.0mmol/L) (checked on two occa-sions). Once insulin therapy isstarted, a target glucose rangeof 140180 mg/dL (7.810.0mmol/L) is recommend
24、ed forthe majority of critically ill andnoncritically ill patients. A16.5 More stringent goals, such as110140 mg/dL (6.17.8 mmol/L),may be appropriate for selectedpatients if they can be achievedwithout significant hypoglyce-mia. CStandard Definitions of GlucoseAbnormalitiesHyperglycemia in hospital
25、ized patientsis defined as blood glucose levels 140mg/dL (7.8 mmol/L) (2,3,25). Blood glu-cose levels persistently above this levelshould prompt conservative interven-tions, such as alterations in diet orchangestomedicationsthatcausehyperglycemia. An admission A1C value$6.5% (48 mmol/mol) suggests t
26、hatthe onset of diabetes preceded hospital-ization (see Section 2, “Classificationand Diagnosis of Diabetes,” https:/doi.org/10.2337/dc22-S002) (2,25). Hypo-glycemia in hospitalized patients is cate-gorized by blood glucose concentrationand clinical correlates (Table 6.4) (26):Level1hypoglycemiaisag
27、lucoseconcentration 5470 mg/dL (3.03.9mmol/L). Level 2 hypoglycemia is ablood glucose concentration 54 mg/dL(3.0 mmol/L), which is typically thethresholdforneuroglycopenicsymp-toms. Level 3 hypoglycemia is a clinicalevent characterized by altered mentaland/or physical functioning that requiresassist
28、ancefromanotherpersonforrecovery. Levels 2 and 3 require immedi-ate correction of low blood glucose.Glycemic TargetsIn a landmark clinical trial, Van denBerghe et al. (27) demonstrated that anintensive intravenous insulin regimen toreach a target glycemic range of 80110mg/dL (4.46.1 mmol/L) reduced
29、mor-tality by 40% compared with a standardapproach targeting blood glucose of180215 mg/dL (1012 mmol/L) in criti-cally ill patients with recent surgery.This study provided robust evidencethat active treatment to lower bloodglucose in hospitalized patients hadimmediate benefits. However, a large,mult
30、icenter follow-up study, the Normo-glycemia in Intensive Care Evaluationand Survival Using Glucose AlgorithmRegulation (NICE-SUGAR) trial (28), ledto a reconsideration of the optimal tar-get range for glucose lowering in criticalillness. In this trial, critically ill patientsrandomized to intensive
31、glycemic con-trol (80110 mg/dL) derived no signifi-cant treatment advantage comparedwith a group with more moderate glyce-mic targets (140180 mg/dL 7.810.0mmol/L) and, in fact, had slightly butsignificantly higher mortality (27.5% vs.25%). The intensively treated group had10- to 15-fold greater rate
32、s of hypogly-cemia, which may have contributed tothe adverse outcomes noted. The find-ings from NICE-SUGAR are supported byseveral meta-analyses, some of whichsuggestthattightglycemiccontrolincreasesmortalitycomparedwithcare.diabetesjournals.orgDiabetes Care in the HospitalS245Downloaded from http:/
33、diabetesjournals.org/care/article-pdf/45/Supplement_1/S244/636895/dc22s016.pdf by guest on 10 July 2022more moderate glycemic targets andgenerally causes higher rates of hypo-glycemia(2931).Basedontheseresults, insulin therapy should be initi-ated for treatment of persistent hyper-glycemia $180 mg/d
34、L (10.0 mmol/L)and targeted to a glucose range of140180 mg/dL (7.810.0 mmol/L) forthe majority of critically ill patients.Although not as well supported by datafrom randomized controlled trials, theserecommendations have been extendedto hospitalized patients without criticalillness. More stringent g
35、oals, such as110140 mg/dL (6.17.8 mmol/L), maybe appropriate for selected patients(e.g., critically ill postsurgical patients orpatients with cardiac surgery), as long asthey can be achieved without significanthypoglycemia(32,33).Ontheotherhand, glucose concentrations between180 mg/dL and 250 mg/dL
36、(1013.9mmol/L) may be acceptable in patientswith severe comorbidities and in inpa-tient care settings where frequent glu-cosemonitoringorclosenursingsupervision is not feasible. Glycemic lev-els above 250 mg/dL (13.9 mmol/L) maybe acceptable in terminally ill patientswith short life expectancy. In t
37、hesepatients, less aggressive insulin regimensto minimize glucosuria, dehydration, andelectrolyte disturbances are often moreappropriate. Clinical judgment combinedwith ongoing assessment of clinical sta-tus, including changes in the trajectoryof glucose measures, illness severity,nutritional status
38、, or concomitant medi-cations that might affect glucose levels(e.g., glucocorticoids), should be incorpo-ratedintotheday-to-daydecisionsregarding insulin dosing (34).BEDSIDE BLOOD GLUCOSEMONITORINGIn hospitalized patients with diabeteswhoareeating,bedsideglucosemonitoringshouldbeperformedbefore meal
39、s; in those not eating,glucose monitoring is advised every46 h (2). More frequent bedsideblood glucose testing ranging fromevery 30 min to every 2 h is therequired standard for safe use ofintravenous insulin. Safety standardsfor blood glucose monitoring thatprohibit the sharing of lancets, othertest
40、ing materials, and needles aremandatory (35).The vast majority of hospital glucosemonitoring is performed using standardglucose monitors and capillary bloodtaken from fingersticks, similar to theprocess used by outpatients for homeglucose monitoring (36). Point-of-care(POC) meters are not as accurat
41、e or asprecise as laboratory glucose analyzers,and capillary blood glucose readings aresubject to artifact due to perfusion,edema, anemia/erythrocytosis, and sev-eral medications commonly used in thehospital (37). The U.S. Food and DrugAdministration(FDA)hasestablishedstandards for capillary (finger
42、stick) bloodglucose meters used in the ambulatorysetting, as well as standards to beapplied for POC measures in the hospital(37).Thebalancebetweenanalyticrequirements (e.g., accuracy, precision,interference) and clinical requirements(rapidity, simplicity, point of care) hasnot been uniformly resolve
43、d (36,38), andmosthospitals/medicalcentershavearrived at their own policies to balancethese parameters. It is critically impor-tant that devices selected for in-hospitaluse, and the workflow through whichthey are applied, have careful analysis ofperformance and reliability and ongoingquality assessm
44、ents. Recent studies indi-cate that POC measures provide ade-quate information for usual practice,with only rare instances where care hasbeen compromised (39,40). Good prac-tice dictates that any glucose result thatdoes not correlate with the patients clin-ical status should be confirmed throughmeas
45、urement of a serum sample in theclinical laboratory.Continuous Glucose MonitoringReal-time continuous glucose monitoring(CGM) provides frequent measurementsof interstitial glucose levels as well asthe direction and magnitude of glucosetrends. Even though CGM has theoreticaladvantages over POC glucos
46、e testing indetecting and reducing the incidence ofhypoglycemia, it has not been approvedby the FDA for inpatient use. Some hos-pitals with established glucose manage-ment teams allow the use of CGM inselected patients on an individual basis,provided both the patients and the glu-cose management tea
47、m are well edu-cated in the use of this technology. CGMis not approved for intensive care unituse.During the COVID-19 pandemic, sev-eral institutions used CGM to minimizecontact between health care providersand patients, especially those in theintensive care unit (4149). This approachseems to be hel
48、pful in that regard, aswell as helping to minimize the use ofpersonal protective equipment. Unfortu-nately, the data about the use of CGMto improve either glycemic control orhospitalization outcomes are not yetavailable.Preliminarydatathatarealready at hand suggest that CGM canoffer significant impr
49、ovement to bothglycemiccontrolandoutcomesofhospitalization.For more information on CGM, seeSection 7, “Diabetes Technology” (https:/doi.org/10.2337/dc22-S007).GLUCOSE-LOWERING TREATMENTIN HOSPITALIZED PATIENTSRecommendations16.6 Basal insulin or a basal plusbolus correction insulin regi-men is the p
50、referred treatmentfor noncritically ill hospitalizedpatients with poor oral intakeor those who are taking noth-ing by mouth. A16.7 An insulin regimen with basal,prandial, and correction compo-nents is the preferred treatmentfor noncritically ill hospitalizedpatients with good nutritionalintake. A16.
