The American Diabetes Association [ADA] “Standards of Medical Care in Diabetes” includes the 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 multidisciplinary expert committee [//doi.org/10.2337/dc22-SPPC], are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA’s clinical practice recommendations, please refer to the Standards of Care Introduction [//doi.org/10.2337/dc22-SINT]. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
Among hospitalized patients, hyperglycemia, hypoglycemia, and glucose variability are associated with adverse outcomes, including death [1–3]. Therefore, careful management of inpatients with diabetes has direct and immediate benefits. Hospital management of diabetes is facilitated by preadmission treatment of hyperglycemia in patients having elective procedures, a dedicated inpatient diabetes service applying well-developed standards, and careful transition out of the hospital to prearranged outpatient management. These steps can shorten hospital stays and reduce the need for readmission, as well as improve patient outcomes. Some in-depth reviews of hospital care for patients with diabetes have been published [3–5]. For older hospitalized patients or for patients in the long-term care facilities, please see Section 13, “Older Adults” [//doi.org/10.2337/dc22-S013].
Hospital Care Delivery Standards
Recommendations
16.1 Perform an A1C test on all patients with diabetes or hyperglycemia [blood glucose >140 mg/dL [7.8 mmol/L]] admitted to the hospital if not performed in the prior 3 months. B
16.2 Insulin should be administered using validated written or computerized protocols that allow for predefined adjustments in the insulin dosage based on glycemic fluctuations. B
Considerations on Admission
High-quality hospital care for diabetes requires standards for care delivery, which are best implemented using structured order sets, and quality assurance for process improvement. Unfortunately, “best practice” protocols, reviews, and guidelines [2–4] are inconsistently implemented within hospitals. To correct this, medical centers striving for optimal inpatient diabetes treatment should establish protocols and structured order sets, which include computerized physician order entry [CPOE].
Initial orders should state the type of diabetes [i.e., type 1, type 2, gestational diabetes mellitus, pancreatic diabetes] when it is known. Because inpatient treatment and discharge planning are more effective if based on preadmission glycemia, an A1C should be measured for all patients with diabetes or hyperglycemia admitted to the hospital if the test has not been performed in the previous 3 months [6–9]. In addition, diabetes self-management knowledge and behaviors should be assessed on admission and diabetes self-management education provided, if appropriate. Diabetes self-management education should include appropriate skills needed after discharge, such as medication dosing and administration, glucose monitoring, and recognition and treatment of hypoglycemia [2,3]. There is evidence to support preadmission treatment of hyperglycemia in patients scheduled for elective surgery as an effective means of reducing adverse outcomes [10–13].
The National Academy of Medicine recommends CPOE to prevent medication-related errors and to increase efficiency in medication administration [14]. 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 [15]. 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 [16,17].
Diabetes Care Providers in the Hospital
Recommendation
16.3 When caring for hospitalized patients with diabetes, consult with a specialized diabetes or glucose management team when possible. C
Appropriately trained specialists or specialty teams may reduce the length of stay, improve glycemic control, and improve outcomes [10,18,19]. In addition, the greater risk of 30-day readmission following hospitalization that has been attributed to diabetes can be reduced and costs saved when inpatient care is provided by a specialized diabetes management team [20,21]. In a cross-sectional comparison of usual care to management by specialists who reviewed cases and made recommendations solely through the electronic medical record, rates of both hyper- and hypoglycemia were reduced 30–40% by electronic “virtual care” [22]. Details of team formation are available in the Joint Commission standards for programs and from the Society of Hospital Medicine [23,24].
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 [23], and the Society of Hospital Medicine has a workbook for program development [24].
Glycemic Targets In Hospitalized Patients
Recommendations
16.4 Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold ≥180 mg/dL [10.0 mmol/L] [checked on two occasions]. Once insulin therapy is started, a target glucose range of 140–180 mg/dL [7.8–10.0 mmol/L] is recommended for the majority of critically ill and noncritically ill patients. A
16.5 More stringent goals, such as 110–140 mg/dL [6.1–7.8 mmol/L], may be appropriate for selected patients if they can be achieved without significant hypoglycemia. C
Standard Definitions of Glucose Abnormalities
Hyperglycemia in hospitalized patients is defined as blood glucose levels >140 mg/dL [7.8 mmol/L] [2,3,25]. Blood glucose levels persistently above this level should prompt conservative interventions, such as alterations in diet or changes to medications that cause hyperglycemia. An admission A1C value ≥6.5% [48 mmol/mol] suggests that the onset of diabetes preceded hospitalization [see Section 2, “Classification and Diagnosis of Diabetes,” //doi.org/10.2337/dc22-S002] [2,25]. Hypoglycemia in hospitalized patients is categorized by blood glucose concentration and clinical correlates [Table 6.4] [26]: Level 1 hypoglycemia is a glucose concentration 54–70 mg/dL [3.0–3.9 mmol/L]. Level 2 hypoglycemia is a blood glucose concentration