Of these 25 million people, it is estimated that nearly 7 million are unaware that they have the disease until faced with associated complications.
Members of the ADA Professional Practice Committeea multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. Readers who wish to comment on the Standards of Care are invited to do Care of the perioperative diabetic patient at professional.
In the hospital, both hyperglycemia and hypoglycemia are associated with adverse outcomes, including death 12. Therefore, inpatient goals should include the prevention of both hyperglycemia and hypoglycemia. Hospitals should promote the shortest safe hospital stay and provide an effective transition out of the hospital that prevents acute complications and readmission.
For in-depth review of inpatient hospital practice, consult recent reviews that focus on hospital care for diabetes 34. B High-quality hospital care for diabetes requires both hospital care delivery standards, often assured by structured order sets, and quality assurance standards for process improvement.
To correct this, hospitals have established protocols for structured patient care and structured order sets, which include computerized physician order entry CPOE. Considerations on Admission Initial orders should state the type of diabetes i. Because inpatient insulin use 5 and discharge orders 6 can be more effective if based on an A1C level on admission 7perform an A1C test on all patients with diabetes or hyperglycemia admitted to the hospital if the test has not been performed in the prior 3 months.
In addition, diabetes self-management knowledge and behaviors should be assessed on admission and diabetes self-management education DSME should be provided, if appropriate.
DSME should include appropriate skills needed after discharge, such as taking antihyperglycemic medications, monitoring glucose, and recognizing and treating hypoglycemia 2. Physician Order Entry Recommendation Insulin should be administered using validated written or computerized protocols that allow for predefined adjustments in the insulin dosage based on glycemic fluctuations.
A Cochrane review of randomized controlled trials using computerized advice to improve glucose control in the hospital found significant improvement in the percentage of time patients spent in the target glucose range, lower mean blood glucose levels, and no increase in hypoglycemia 9. Thus, where feasible, there should be structured order sets that provide computerized advice for glucose control.
Electronic insulin order templates also improve mean glucose levels without increasing hypoglycemia in patients with type 2 diabetes, so structured insulin order sets should be incorporated into the CPOE Diabetes Care Providers in the Hospital Appropriately trained specialists or specialty teams may reduce length of stay, improve glycemic control, and improve outcomes, but studies are few 11 A call to action outlined the studies needed to evaluate these outcomes Details of team formation are available from the Society of Hospital Medicine and the Joint Commission standards for programs.
Quality Assurance Standards Even the best orders may not be carried out in a way that improves quality, nor are they automatically updated when new evidence arises. To this end, the Joint Commission has an accreditation program for the hospital care of diabetes 14and the Society of Hospital Medicine has a workbook for program development Blood glucose levels that are persistently above this level may require alterations in diet or a change in medications that cause hyperglycemia.
Severe hypoglycemia is defined as that associated with severe cognitive impairment regardless of blood glucose level Conversely, higher glucose ranges may be acceptable in terminally ill patients, in patients with severe comorbidities, and in inpatient care settings where frequent glucose monitoring or close nursing supervision is not feasible.
In the patient who is not eating, glucose monitoring is advised every 4—6 h 2. More frequent blood glucose testing ranging from every 30 min to every 2 h is required for patients receiving intravenous insulin.
Safety standards should be established for blood glucose monitoring that prohibit the sharing of fingerstick lancing devices, lancets, and needles Food and Drug Administration FDA has standards for blood glucose meters used by lay persons, there have been questions about the appropriateness of these criteria, especially in the hospital and for lower blood glucose readings Significant discrepancies between capillary, venous, and arterial plasma samples have been observed in patients with low or high hemoglobin concentrations and with hypoperfusion.Learn how UpToDate can help you.
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The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes” includes ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care.
Members of the ADA [Professional Practice Committee], a . The use of effective communication among patients and healthcare professionals is critical for achieving a patient's optimal health outcome.
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