March 8, 2013

Diabetes Care in the Hospital

This section of “Standards of Medical Care in Diabetes—2013” is often ignored until hospitalization is necessary and often there is not time to read this unless you have access to a tablet and the internet while in the hospital. Most hospitals do not have internet access available to patients. There is some good information about hospitalization and what you can expect. Much of it is not patient friendly if you are a person with diabetes that likes to manage your diabetes very tightly. If you are unable to communicate and are hospitalized, be prepared to have your blood glucose levels managed in the range for allowing complications to set in.

Understand that hospitals have the ranges set to prevent hypoglycemia, as this is a fear they have, especially if they do not have an endocrinologist specializing in diabetes available or do not have high levels of confidence in the nursing staff. The recommendations are:

1. All patients with diabetes admitted to the hospital should have their diabetes clearly identified in the medical record.
2. All patients with diabetes should have an order for blood glucose monitoring, with results available to all members of the health care team.
3. Goals for blood glucose levels:
1. Critically ill patients: Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold of no greater than 180 mg/dL (10 mmol/L). Once insulin therapy is started, a glucose range of 140–180 mg/dL (7.8–10 mmol/L) is recommended for the majority of critically ill patients.
2. More stringent goals, such as 110–140 mg/dL (6.1–7.8 mmol/L) may be appropriate for selected patients, as long as this can be achieved without significant hypoglycemia.
3. Critically ill patients require an intravenous insulin protocol that has demonstrated efficacy and safety in achieving the desired glucose range without increasing risk for severe hypoglycemia.
4. Scheduled subcutaneous insulin with basal, nutritional, and correction components is the preferred method for achieving and maintaining glucose control in non–critically ill patients.
5. Glucose monitoring should be initiated in any patient not known to be diabetic who receives therapy associated with high risk for hyperglycemia, including high-dose glucocorticoid therapy, initiation of enteral or parenteral nutrition, or other medications such as octreotide or immunosuppressive medications. If hyperglycemia is documented and persistent, consider treating such patients to the same glycemic goals as patients with known diabetes.
6. A hypoglycemia management protocol should be adopted and implemented by each hospital or hospital system. A plan for preventing and treating hypoglycemia should be established for each patient. Episodes of hypoglycemia in the hospital should be documented in the medial record and tracked.
7. Consider obtaining an A1C on patients with diabetes admitted to the hospital if the result of testing in the previous 2–3 months is not available.
8. Consider obtaining an A1C in patients with risk factors for undiagnosed diabetes who exhibit hyperglycemia in the hospital.
9. Patients with hyperglycemia in the hospital who do not have a prior diagnosis of diabetes should have appropriate plans for follow-up testing and care documented at discharge.”

The above are reasonable goals (not ideal) for people in the hospital that are unable to manage their diabetes. For type 1 diabetes patients these may well be ideal goals, but for people with type 2 diabetes, these goals need revision at some point or once the patient is fully capable of managing their own diabetes, this should be allowed with supervision.

One word of warning, if you are the patient, a family member, a friend, or advocate, please insist that the nurse change the lancet in your presence. Many nurses use the same lancet for many patients and have no knowledge of how dangerous this can be, or if they know, don't care.

For most staff in hospitals and even nursing homes, numbers are just that – numbers. They look at the numbers and consider them variable markers. Yes, it says treatment of persistent hyperglycemia starting at a threshold of no greater than 180 mg/dl (10 mmol/L), but this may mean any number as long as it can be fit to the schedule that fits their work pattern. They don't want to come back and check later or even more times. And, believe it when I say they will make the numbers fit. One of our group was in the hospital recently and we checked his blood glucose after the nurse left the room. The nurse told him that his reading was 160 mg/dl and both of us had meters and checked after that and my reading on him was 262 mg/dl and his own meter gave him a reading of 254 mg/dl. Another one of the group just happened to come to see him then and he set up his meter and the reading was 265 mg/dl.

At that point, we had him use his call button. A different nurse arrived and he asked her what his blood glucose reading had been. She had us step out of the room and then read his chart. When she left, we went back and he said that she had told him 160 mg/dl. He said that was wrong and that his reading was almost 100 mg/dl higher. He said she was going to get another meter and would be back. So we waited for almost an hour for her to return. This time she was accompanied by security and asked us to leave the room. While we were out, we could hear some of what was happening and as we suspected, they were searching for his meter. Then when they were done, they wanted to search us. We laughed at them and commented about how dictatorial they were and since we were only visitors, they had no right to search us. With that we were asked to leave the hospital.

When we returned to Tim's residence, he had a phone message that after we had left, they had done another search, but found nothing. Our friend had wisely sent his meter and other supplies home with us. Since he was being discharged the next day, we decided not to see him until then. The things he told us were unreal and his advice was to avoid that hospital if you valued your life. They had used the same equipment for several patients and would not change the lancet in his presence. When his daughter had arrived to take him home, she was not allowed to see him until he was wheeled out to the car.

Yes, this is unusual, but not unexpected for that hospital, about an hour distant. Our friend said that he would avoid that hospital in the future and go to one of the larger hospitals if at all possible in the future. His daughter had stopped by and picked up her father's diabetes supplies before picking up her dad and he was happy to have them. Blood glucose was over 300 mg/dl so he was able to correct with insulin and is back to managing his blood glucose very effectively.

Tim and I had a long conversation with him and his daughter about hospital diabetes care and Tim did ask why he had not gotten permission to manage his own diabetes. He said that he had asked and was told this was not allowed and since he was only going to be there for three days, he did not think too much could go wrong. He now knows better and was glad we were there to take his diabetes supplies, which he had taken in with him. He remarked that he never suspected they would search his room so thoroughly after questioning the blood glucose reading. He said the nurses would not talk to him after that and were anything but polite when they had to make their rounds. Read what I have written before about hospital diabetes care.

The ADA guidelines are much more in line with good management (I did not say great management) than that adopted by a majority of hospitals. Therefore, know your rights and if possible have your care done by yourself with agreements beforehand and have extra copies to hand out to staff that want care only their way. If necessary, get your doctor involved as well.

Number 8 in the quoted area above is the new addition that ADA wants hospitals to add to their admitting policy. To repeat #8, “8. Consider obtaining an A1C in patients with risk factors for undiagnosed diabetes who exhibit hyperglycemia in the hospital.”
This means that if you may be at risk for diabetes, hospitals are requested by the ADA to obtain the A1c. Then if this shows positive, they are to repeat this on another day to confirm diabetes.

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