Hyperglycemia Management in the Hospital: About Glucose Targets and Process Improvements

Abstract

Hyperglycemia is prevalent in the inpatient setting and is associated with increased morbidity and mortality in patients with and without diabetes. Too often hyperglycemia is underrecognized, underreported, and suboptimally managed. Proactive assessment of inpatients ' glycemic status and aggressive treatment approaches are needed. Improving hyperglycemia management in hospitalized patients provides the hospitalist with an opportunity to positively affect morbidity, mortality, and health care costs. However, intensive insulin therapy can increase the risk of hypoglycemia, which often results in the early abandonment of tight glycemic control strategies, or in some cases, no emphasis on glucose control at all. To achieve glycemic control, individual physicians often implement a variety of insulin strategies. Some strategies can lead to confusion among the health care staff, others to the use of nonphysiologic sliding-scale insulin protocols that result in poor glycemic control, widely fluctuating blood glucose values, and errors in insulin administration. Consequently, the question is whether tight glycemic control strategies should focus on achieving tight glycemic targets with early and intensive insulin therapy, on process improvements aimed at optimal and safe insulin delivery, or a combination of both approaches. The relative importance of each approach must be carefully balanced by integrated health care teams within each institution. If hyperglycemia management is championed from admission through discharge, patients could experience improved outcomes and institutions could achieve substantial health care cost savings.

Keywords:

• inpatient
• hyperglycemia
• diabetes
• glycemic targets
• insulin analogs
• basal-bolus