Obstacles to optimal management of inpatient hyperglycemia in noncritically ill patients

Compelling evidence continues to evolve linking hyperglycemia in hospitalized patients with adverse clinical outcomes. In 2012, The Endocrine Society's clinical practice guidelines for management of hyperglycemia in non-critical care settings were published, and explicit blood glucose targets for noncritically ill patients were recommended. These matched those set by the American Diabetes Association (ADA) in the Standards of Medical Care in Diabetes--2012. Although there are more specific targets for achieving optimal glycemic control in critically ill and noncritically ill inpatients, implementing standardized processes to achieve these goals continues to remain a challenge. This article summarizes these obstacles and emphasizes the quality of care and safety issues (eg, hypoglycemia and insulin errors) that are associated with the management of hyperglycemia in hospitalized patients. The use of intravenous insulin via computerized or manual standardized protocols in critically ill patients has been shown to be effective in achieving glucose control; we focus on the barriers to the appropriate use of subcutaneous insulin in hospitalized patients with noncritical illness. We also elaborate on how to overcome most of these obstacles and the clinical inertia to treat hyperglycemia through focused education and surveillance, and then "re-education," using a multidisciplinary, collaborative approach. Transition from intravenous insulin to subcutaneous insulin, and transition from an inpatient to an outpatient glycemic regimen at the time of discharge, are identified as aspects of management that require extra attention. We also emphasize the need for a multidisciplinary task force responsible for monitoring and enhancing glycemic control practices in the hospital on an ongoing basis.     

Inpatient management of diabetes and hyperglycemia: implications for nutrition practice and the food and nutrition professional

Although numerous guidelines and standards address the management of diabetes in outpatient settings, only recently has evidence been provided to issue standards of care to guide clinicians in optimal inpatient glycemic control for hospitalized individuals with diabetes or illness-induced hyperglycemia. Both the American Diabetes Association and the American College of Endocrinology recommend critically ill patients keep their blood glucose level as close to 110 mg/dL (6.1 mmol/L) as possible. In the noncritically ill patient, the American Diabetes Association recommends to keep pre-meal blood glucose as close to 90 to 130 mg/dL (5.0 to 7.2 mmol/L) as possible, whereas the American College of Endocrinology recommends pre-meal blood glucose be kept at 110 mg/dL (6.1 mmol/L) or less. Both organizations agree that peak post-prandial blood glucose should be 180 mg/dL (10.0 mmol/L) or less. Recent evidence has also led the Joint Commission on Accreditation of Healthcare Organizations to develop standards for a voluntary certification in the management of the patient with diabetes in the inpatient setting. It is important that food and nutrition professionals familiarize themselves with these recommendations and implement nutrition interventions in collaboration with other members of the health care team to achieve these new glycemic control targets. Food and nutrition professionals have a key role in developing screening tools, and in implementing nutrition care guidelines, nutrition interventions, and medical treatment protocols needed to improve inpatient glycemic control.     

Glycemic control and nutrition in the intensive care unit

PURPOSE OF REVIEW: Hospital clinicians frequently encounter hyperglycemia due to diabetes or the stress of critical illness in patients who are receiving nutrition support. RECENT FINDINGS: A growing body of evidence suggests that hyperglycemia in the hospital is associated with adverse outcomes (e.g. disability after acute cardiovascular events, infection and death) and that improvement in outcomes can be achieved with improved glycemic control or insulin. Therefore, familiarity with the implications of hyperglycemia and with its treatment are essential for clinicians practicing in hospital settings. SUMMARY: Questions persist regarding the optimal glucose goal range in differing patient groups. In addition, while the technology to deliver glycemic control in intensive care unit settings is widely available, data are limited about effective and safe insulin infusions. Research should focus on the risks and benefits of providing nutrition support in this group of patients, optimal glucose goal ranges, and on methods of achieving desired glucose goal ranges.     

Initiatives to Promote Effective Self-Care Skills in Children and Adolescents with Diabetes Mellitus

Intensive management of type 1 diabetes mellitus (T1DM) is increasingly becoming the ‘ideal’ standard of care for pediatric patients at diabetes centers across the world. This ‘ideal’ standard is based on two landmark studies that documented that keeping blood glucose levels as close to normal as possible and achieving this as early as possible in the disease course helps to prevent or delay the devastating long-term complications of T1DM. Simultaneously, initiatives supplemental to the medical care of young patients with diabetes that are attempting to improve the self-care behavior and glycemic control of young patients with diabetes have been implemented. There is consensus among recent meta-analyses and critical reviews of these interventions that their overall impact on glycemic control is modest to moderate at best. Because of the need for healthcare cost containment and allocation of resources, we have attempted to identify the components of these different initiatives that have the potential to be practical, cost saving, and integrated into the routine clinical care of diabetes. Interventions based on coping-skills training, motivational interviewing, behavioral family systems therapy, and multisystemic therapy models require the expertise of a highly trained mental healthcare professional. Moreover, none of these interventions has yet been implemented or evaluated within the ongoing context of routine ambulatory diabetes care. Finally, each of these interventions requires additional time commitments from young patients with diabetes and their families.The Care Ambassador intervention and programs based on the Family Teamwork intervention do not require highly trained, expensive staff for delivery and have been successfully integrated into routine pediatric diabetes-care settings. Moreover, the Care Ambassador model has also been shown to reduce expensive adverse outcomes across a broad spectrum of youth with diabetes. Finally, telehealth interventions for youth with diabetes may hold great potential as a lower-cost intervention to supplement routine diabetes care and to optimize glycemic control for pediatric patients; however, we await the rigorous evaluation of the application of telehealth interventions across a range of outpatient pediatric diabetes-care settings. Pediatric diabetes care requires an environment of supportive, collaborative communication grounded in realistic expectations for youths. Thus, ongoing evaluations of outcomes of these various interventions are needed within multiple healthcare settings.     

Management of parenteral nutrition in acutely ill patients with hyperglycemia.

Many hospital clinicians manage patients with hyperglycemia receiving nutrition support. Recent studies underscore the importance of tight glucose control in hospitalized patients. Over the short term, hyperglycemia can adversely affect fluid balance, immune function, inflammation, and outcome; glucose control can improve these effects. Because this appears to be true for patients with and without a known diagnosis of diabetes, hyperglycemia should be aggressively treated in all patients. Avoidance or minimization of hypoglycemia also is important. In general, the nutrition assessment, indications for nutrition support, and estimate of nutrition requirements for critically ill patients with hyperglycemia are similar to those of nondiabetic patients. Because overfeeding may cause hyperglycemia, appropriate provision of calories is essential. Although the technology to deliver tight glycemic control in intensive care unit settings is widely available, implementing a safe and effective program requires standardized approaches. Studies testing which insulin infusion safely achieves tight glucose control are limited. Further research should focus on the risks and benefits of parenteral nutrition use in this group of patients, as well as on optimal methods of achieving glucose control.     

Neonates as intrinsically worthy recipients of pain management in neonatal intensive care

One barrier to optimal pain management in the neonatal intensive care unit (NICU) is how the healthcare community perceives, and therefore manages, neonatal pain. In this paper, we emphasise that healthcare professionals not only have a professional obligation to care for neonates in the NICU, but that these patients are intrinsically worthy of care. We discuss the conditions that make neonates worthy recipients of pain management by highlighting how neonates are (1) vulnerable to pain and harm, and (2) completely dependent on others for pain management. We argue for a relational account of ethical decision-making in the NICU by demonstrating how an increase in vulnerability and dependence may be experienced by the healthcare community and the neonate’s family. Finally, an ethical framework for decisions around neonatal pain management is proposed, focussing on surrogate decision-making and the importance of compassionate action through both a reflective and an affective empathy. As empathy can be highly motivating against pain, we propose that, in addition to educational programs that raise awareness and knowledge of neonatal pain and pain management, healthcare professionals must cultivate empathy in a collective manner, where all members of the NICU team, including parents, are compassionate decision-makers.

     

Hyperglycemia during critical illness

BACKGROUND: We sought to review the literature describing the benefits of tight glycemic control in critically ill patients, comparing outcome differences in subgroup populations. METHODS: We searched PubMed for relevant literature on the topic of hyperglycemia and its management in the intensive care unit. RESULTS: Overwhelming evidence in both surgical and medical patients conclusively demonstrates that hyperglycemia is a marker of severity of illness and is also an independent determinant of bad outcome, largely from infectious complications. Randomized trial evidence, in conjunction with historically controlled trials, supports the use of intensive insulin therapy and euglycemic control in critically ill patients, with nondiabetics possibly benefiting even more than diabetic patients. Euglycemia is best achieved, and hypoglycemia attenuated, through use of a protocolized approach. Further elaboration as to what threshold range defines euglycemia in patient subpopulations is needed and what pitfalls must be avoided in this practice. Development of continuous blood glucose monitoring has started and will someday be incorporated into routine practice in the same way that continuous electrocardiographic monitoring and pulse oximetry are standards of care in the intensive care unit. CONCLUSIONS: Hyperglycemia is a predictor of death and complications in critically ill patients. Early aggregated study results show that control of hyperglycemia improves outcomes. Well-designed studies involving thousands of patients have started to better elucidate the concomitant promoters of hyperglycemia and to better quantify the benefits from tight glycemic control.     

Understanding glycemic control in the critically ill: 2011 update

Intensive monitoring of blood glucose concentrations in critically ill patients has become a standard of care in intensive care units over the past 10 years, following the publication of a single-center randomized trial targeting euglycemia in postoperative patients. This article summarizes the literature describing the relationship between hyperglycemia and mortality in the critically ill, the main findings of the major interventional trials of intensive insulin therapy, the association between hypoglycemia and increased glycemic variability with adverse outcomes, and the impact of a preexisting diagnosis of diabetes. A framework for understanding dysglycemia in the critically ill, an approach that recognizes disturbances in the "3 domains" of glycemic control--hyperglycemia, hypoglycemia, and increased glycemic variability--is presented. Finally, practical considerations relating to the implementation of glycemic management protocols are discussed.     

Incretin-Based Therapies: Review of the Outpatient Literature with Implications for Use in the Hospital and After Discharge

Abstract

A large percentage of critically ill adult inpatients have type 2 diabetes, which may be undiagnosed or uncontrolled during hospitalization. Hyperglycemia complicates the therapeutic management of inpatients and leads to adverse outcomes, and intensive glycemic control with insulin reduces morbidity and mortality. Insulin therapy, however, is labor-intensive and time-consuming. More important, long-standing protocols such as the sliding scale do not provide adequate glucose control. Although more research is needed to determine the best methods for treating hyperglycemia in-hospital, the importance of achieving better glycemic control while reducing the risk of hypoglycemia has been demonstrated. Post-discharge diabetes care is equally important, as it is essential in improving long-term outcomes after a hospital stay. Hospital care providers can play an important role in effective antihyperglycemic regimens in patients with diabetes prior to discharge. Post-discharge management is a formidable challenge because of the availability of an array of oral antidiabetes agents, including metformin, sulfonylureas, and thiazolidinediones, each with distinct therapeutic and adverse event profiles. Incretin-based therapies offer a potentially useful option for post-discharge therapy, and possibly for inpatient diabetes treatment. Incretins are effective, safe, and well-tolerated; they are easier for patients to use compared with insulin injections (eg, continual glucose monitoring is not required); and they may provide long-term improvement of cardiovascular parameters and β-cell function. This review examines the challenges to achieving glycemic control in the hospital setting and summarizes clinical data on the efficacy and safety of incretin-based therapies in their use in the hospital and after discharge.     

An institutional process to improve inpatient glycemic control

Many institutions are evaluating their inpatient patterns of care for patients with diabetes mellitus and hyperglycemia, based upon compelling evidence that strict glycemic control improves outcomes in a variety of hospital settings. In 2005, a multidisciplinary task force was established at the University of Kentucky Chandler Medical Center in Lexington, Kentucky, to guide a process to improve the quality and safety of inpatients with hyperglycemia. This article describes the stepwise process including an examination of our procedures, adoption of standards, and establishment of common protocols and procedures. Successful implementation of the protocols was preceded by extensive educational efforts. Refinement of the protocols based on early experience and feedback from staff has resulted in improvements in glycemic parameters and less reliance on sliding scale insulin regimens.