1. Management of Inpatient Hyperglycemia: Review of Recent Trials and Guidelines
Bruce W. Bode, MD FACE
Atlanta Diabetes Associates
Associate Professor of Medicine
Emory University School of Medicine

2. Financial Relationships
Grant/Research Support: Sanofi-Aventis, Lilly USA, Novo Nordisk
Consultant: Sanofi-Aventis, Lilly USA, Novo Nordisk
Speaker’s Bureau: Sanofi-Aventis, Lilly USA, Novo Nordisk
Major Stock Shareholder : Glytec

3. Diabetes Today: An Epidemic
In 2008, ~26 million Americans (12% of the population) were diagnosed with diabetes1
In 2008, 40% of Americans >age 20 have either pre-DM or DM
Complications of diabetes are a major cause of mortality and morbidity1
>224,000 deaths
82,000 lower-limb amputations
44,000 began treatment for end-stage kidney disease
12,000-24,000 new cases of blindness each year
Total cost in the United States in 2002: $132 billion1
Diabetes Today: An Epidemic
Review as stated.
References
ADA National Diabetes Fact Sheet. Available at: Accessed October 11, 2006.
ADA. The dangerous toll of diabetes. Available at: Accessed October 11, 2006.

4. Hyperglycemia Is Prevalent at Hospital Admission
38% of all patients at admission have hyperglycemia
– Of those patients, nearly one-third have no history of diabetes
Hyperglycemia Is Prevalent at Hospital Admission
The medical records of 2030 consecutive adult patients admitted to a community hospital in Georgia over a 15-week period (July 1, 1998–October 20, 1998) were reviewed to determine the prevalence of in-hospital hyperglycemia and its impact on survival and functional outcome in patients with and without a history of diabetes.
Because 144 patients did not have a blood glucose value, only 1886 patients were eligible for the study.
Hyperglycemia was defined as an admission or in-hospital fasting blood glucose level of 126 mg/dL or more, or random blood glucose levels of 200 mg/dL or more on 2 or more occasions.
Results on admission indicate that 1168 patients were normoglycemic (62%) and 718 were hyperglycemic (38%). Of those who were hyperglycemic, 223 (31%) did not have a previous history of diabetes.
Single-center, retrospective chart review of 1886 patients hospitalized over 15 weeks in a community teaching hospital. Hyperglycemia defined as BG ≥126 mg/dL on admission or while fasting, or random BG ≥200 mg/dL on ≥2 occasions.
Umpierrez GE et al. J Clin Endocrinol Metab. 2002;87:
Reference
Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE. Hyperglycemia:
an independent marker of in-hospital mortality in patients with undiagnosed diabetes.
J Clin Endocrinol Metab. 2002;87:

5. 2007 Total Direct Cost = $116 billion
Hospitalizations Account for the Largest Portion of the Direct Costs of Diabetes Care
2007 Total Direct Cost = $116 billion
50%
American Diabetes Association. Diabetes Care. 2008;31:

6. Hyperglycemia: Scope of the Problem
Diabetes
No Diabetes 50 40 30 20 10 50 40 30 20 10
Patients, %
26%
78%
Using a national database derived from electronic medical records at 39 medical centers, investigators analyzed patterns of blood glucose (BG) control and documented insulin therapy among 16,534 patients hospitalized with acute myocardial infarction from January 2000 to December 2005.
Of the 4940 patients (30%) with recognized diabetes mellitus (DM), nearly half (2412 patients, 49%) had mean BG >200 mg/dL during the first 24 hours after hospital admission. When the entire hospitalization was considered, 34% of DM patients had mean BG >200 mg/dL, while 61% had mean BG between 110 and 200 mg/dL, and only 5% maintained mean BG <110 mg/dL.
Among patients without recognized DM, 8% had mean BG >200 mg/dL during the first 24 hours. When the entire hospitalization was considered, 4% of patients without known DM had mean BG >200 mg/dL, while 65% had mean BG between 110 and 200 mg/dL, and 31% had mean BG <110 mg/dL.
<110
>200
<110
>200
Mean BG, mg/dL
Kosiborod M, et al. J Am Coll Cardiol. 2007;49(9): :283A-284A.
Kosiborod M, Inzucchi S, Clark B, et al. National patterns of glucose control among patients hospitalized with acute myocardial infarction. J Am Coll Cardiol. 2007;49(9): :283A-284A.

7. Hyperglycemia and Mortality in the MICU
~4x
~3x 45 45 45
[Krinsley.MayoClin Proc.Dec.2003/ p1471/Abstract/c1/ line A4-A8; p1476/ Table 7] 40 40 40
~2x 35 35 35 30 30 30
Mortality Rate (%) 25 25 25 20 20 20 15 15 15 10 10 10 5 5 5
80-99
>300
Mean Glucose Value (mg/dL)
N=1826 ICU patients.
Krinsley JS. Mayo Clin Proc. 2003;78:

8. Intensive Insulin Management in Medical-Surgical ICU
P < 0.001
P < 0.002
29.3% Reduction
Non-RCT…
Intensive Insulin Management in Medical-Surgical ICU
Continuous IV insulin was used if glucose values exceeded 200 mg/dL on 2 successive occasions. This protocol resulted in significantly improved glycemic control and was associated with decreased mortality and with no significant increase in nursing requirements.
Mean BG Levels (mg/dL)
Hospital Mortality (%)
Baseline group (n = 800)
Glucose management group (n = 800)
Krinsley JS. Mayo Clin Proc. 79: , 2004.

9. Hyperglycemia: A Predictor of Mortality Following CABG in Diabetics10
[Furnary. Circulation.1999/ pI591/line 8-19]
BG >200
P<0.0001
BG <200
8.6
n=1369
n=662 8
Postop
1.8%
5.0% *
Mortality
*P<0.001
5.8 6
Postop Mortality (%)
Adjusted for 19 clinical and operation variables
3.8 4
Non-RCT – Impact of hyperglycemia following CABG
First Postop Glucose >200
2x LOS
3x Vent duration
7x mortality !!!
2.1
1.7 2
1.4
<150
150-
175-
200-
225-
>250
CABG, coronary artery bypass graft.
175
200
225
250
Furnary AP et al. Circulation. 1999:100 (Suppl I): I-591.
Blood Glucose (mg/dL)

10. Intensive Insulin Therapy in Critically Ill Patients: The Leuven SICU Study
[VandenBerghe. NEJM.Nov.2001/ p1359/Abstract/line A6-A15,p1360/c1/ line 23-43, p1361/ Table 2]
Randomized controlled trial: 1548 patients admitted to a surgical ICU, receiving mechanical ventilation. Patients were assigned to receive either:
Conventional therapy: IV insulin only if BG >215 mg/dL
Target BG levels: mg/dL
Mean daily BG: 153 mg/dL
Intensive therapy: IV insulin if BG >110 mg/dL
Target BG levels : mg/dL
Mean daily BG: 103 mg/dL
First RCT- landmark paper that was the bases for previous guidelines.
Van den Berghe et al. N Engl J Med. 2001;345:

11. Intensive Insulin Therapy in Critically Ill Patients: SICU
[VandenBerghe. NEJM.Nov.2001/ p1362/Table 3, p1365/Table 4] * * * *
Remarkable results! * *
*P<0.01
Relative Risk Reduction (%)
Van den Berghe et al. N Engl J Med. 2001;345:

12. 28%  mortality After 1 year 60%  A Fib post op survival 2 yr
Benefits of Tight Glycemic Control: Observational Studies and Early Intervention Trials
[Kitabchi. Metabolism.2008/ p116/c2/line 19-27, p117/c1/line 1-13]
[Kitabchi/p117/c1/ line 13-28]
[Kitabchi/p116/c1/ line 20-22, c2/ line 1-18]
[Kitabchi/p117/c1/ line 29-34]
[Kitabchi/p118/c1/ line 14-23]
Study
Setting
Population
Clinical Outcome
Furnary, 1999
ICU
DM undergoing open heart surgery
65%  infection
Furnary, 2003
DM undergoing CABG
57%  mortality
Krinsley, 2004
Medical/surgical ICU
Mixed, no Cardiac
29%  mortality
Malmberg, 1995
CCU
Mixed
28%  mortality After 1 year
Van den Berghe, 2001*
Surgical ICU
Mixed, with CABG
42%  mortality
Lazar, 2004
OR and ICU
CABG and DM
60%  A Fib post op survival 2 yr
Summary of early trials – most of them non-RCT
*RCT, randomized clinical trial.
Kitabchi & Umpierrez. Metabolism. 2008;57:

13. Medical ICU Study Results
In-hospital mortality for patients who were in the ICU and on CII for >3 days was lower (52.5% to 43.0%)
- RRR=18.1% P=.009
In-hospital morbidity was lower
- Reduction in newly acquired kidney injury
- Weaning from mechanical ventilation
- Discharge from ICU; discharge from Hospital
Hypoglycemia was an independent risk factor for mortality
Van den Berghe et al. N Engl J Med. 2006;354:

14. Tight Glycemic Control Decreased Morbidity in Medical ICU Patients
Weaning From Mechanical
Ventilation
Discharge From ICU
Discharge From Hospital
4.0
4.5 5
P=.03
4.0
P=.04
P=.05
3.5
3.5 4
3.0
Intensive treatment
3.0
2.5 3
2.5
2.0
Cumulative hazard
2.0
Conventional treatment 2
1.5
1.5
1.0
1.0 1
0.5
0.5
Tight Glycemic Control Decreased Morbidity in Medical ICU Patients
Prospective, randomized, controlled study of adult patients admitted to the medical ICU, N=1200.
On admission, patients were randomly assigned to intensive treatment (IV treatment to maintain blood glucose between mg/dL) or to conventional treatment (IV treatment given only when the blood glucose level >215 mg/dL and tapered when BG <180 mg/dL).
The primary outcome of the study was all-cause mortality during hospitalization. A predefined subgroup analysis for patients staying in the ICU for ≥3 days was also performed.
Intensive therapy significantly reduced morbidity but not in-hospital mortality. Reductions in morbidity were reflected by a reduction in newly acquired kidney injury, earlier weaning from the ventilator, earlier discharge from the ICU, and earlier discharge from the hospital.
For all patients, total ICU and in-hospital mortality were not significantly different.
In-hospital: 37.3% in the intensive treatment group died as compared with 40% in the conventional treatment group (P=.33).
ICU: 24.2% in the intensive treatment group died compared with 26.8% in the conventional treatment group (P=.31).
The predefined subanalysis demonstrated significantly decreased in-hospital mortality and appeared to decrease total ICU mortality among patients with an ICU stay ≥3 days.
In-hospital: Among all patients in the hospital, 43% in the intensive treatment group died compared with 52.5% in the conventional treatment group (P=.009).
ICU: 31.3% in the intensive treatment group died compared with 38.1% in the conventional treatment group (P=.05). 10 20 30 40 50 60 70 80 90 20 40 60 80
100
100
200
300
400
500
600
Days after admission to ICU
Prospective, randomized, controlled study of adult patients admitted to the medical ICU, N= On admission, patients were randomly assigned to intensive treatment or to conventional treatment. Intensive insulin therapy significantly reduced morbidity but not in-hospital mortality.
Van den Berghe G et al. N Engl J Med. 2006;354:
Reference
Van den Berghe G, Wilmer A, Hermans G, et al. Intensive insulin therapy in the medical ICU. N Engl J Med. 2006;354:

15. Intensive Glucose Management in RCT
Trial N
Setting
Primary Outcome
ARR
RRR
Odds Ratio (95% CI)
P-value
Van den Berghe 2006
1200
MICU
Hospital mortality
2.7%
7.0%
0.94* ( )
N.S. HI
240
CCU AMI
6-mo mortality
-1.8%* 
-30%* NR
Glucontrol 2007
1101
ICU
ICU mortality
-1.5%
-10%
1.10* ( )
Ghandi 2007
399 OR
Composite 2%
4.3%
1.0* ( )
VISEP 2008
537
28-d mortality
1.3%
5.0%
0.89* ( )
De La Rosa 2008
504
SICU
-4.2% *
-13%*
NICE-SUGAR 2009
6104
3-mo mortality
 -2.6%
-10.6
1.14 ( )
< 0.05
The slide shows results of trials of glucose management in critical care patients.1-10 Some early randomized trials suggested that intensive glucose lowering can improve outcomes.1,2 However, more recent studies in the critical care population were unable to replicate earlier studies, and identified severe hypoglycemia as a significant risk of intensive glucose control.3-10 In the study by Ghandi et al,7 intensive insulin therapy during cardiac surgery did not reduce perioperative death or morbidity. In the NICE-SUGAR study,10 critically ill patients treated in the intensive glucose control group ( mg/dL) were 14% more likely to die (27.5% vs 24.9%) than were those in the conventional glucose control group ( mg/dL). Severe hypoglycemia (blood glucose ≤40 mg/dL) occurred in 6.8% of the intensive-control group versus 0.5% of the conventional-control group (P<.001).
*not significant

16. NICE-SUGAR NICE-SUGAR Investigators. N Engl J Med 2009;360:1283-97
Trial design: Patients admitted to the ICU were randomized to intensive glucose control ( mg/dl; n = 3,054) vs. conventional glucose control (<180 mg/dl; n = 3,050). Insulin was given intravenously and nutrition was given enterally. Mean BG 115 mg vs 144 mg/dL.
Results
(p = 0.02)
(p < 0.001)
All-cause mortality at 90 days: 27.5% for intensive group vs. 24.9% for conventional group (p = 0.02)
All-cause mortality at 28 days: 22.3% vs. 20.8% (p = 0.17), respectively
Severe hypoglycemia: 6.8% vs. 0.5% (p < 0.001), respectively
27.5
24.9 %
6.8
Conclusions
0.5
Among patients admitted to the ICU, intensive glucose control increased mortality an absolute 2.6% at 90 days (p = ns; CI 0.4 – 4.8)
Severe hypoglycemia was more common in the intensive control group
All-cause mortality at 90 days
Severe hypoglycemia
Intensive glucose control
Conventional glucose control
NICE-SUGAR Investigators. N Engl J Med 2009;360:

17. NICE-SUGAR Study Outcomes
Outcome Measure
Intensive
Group
Conventional Group
Morning BG (mg/dL)
Hypoglycemia
(≤ 40mg/dL)
206/3016
(6.8%)
15/3014
(0.5%)
28 Day Mortality (p=0.17)
22.3%
20.8%
90 Day Mortality (p=0.02)
27.5%
24.9%
The NICE-SUGAR Study Investigators. N Engl J Med. 360: , 2009.

18. NICE-SUGAR: Strengths
Large (N=6104)
2. Multicenter
3. Patients characteristic of a general ICU population
4. Uniformly applied, web-based IV insulin protocol
5. Hard primary endpoint (90-day mortality)
6. Robust analytical plan

19. NICE-SUGAR: Limitations
Specified BG targets & ultimate BG separation (-27 mg/dl) not as distinct as prior trials
2. Treatment target not achieved in the intensive arm.
3. Variable methods/sources for BG measurement
4. More steroid therapy in intensive arm
5. More hypoglycemia in intensive arm (15-fold)
6. No explanation of increased mortality in intensive arm (? hypoglycemia)
7. ~ 10% early withdrawls in intensive arm; ‘per-procotol’ (‘completers’) analysis not provided.

20. Tight Glycemic Control in the Hospital
By normalizing glucose in the hospital, glucose toxicity is broken, improving both insulin secretion and insulin sensitivity
382 Type 2 DM patients, aged 25–70 years, from nine hospital centers in China had their glucose normalized by MDI or CSII for 2 weeks
Remission rates after 1 year were significantly higher in the insulin groups (51% in CSII and 44% in MDI) than in the oral hypoglycaemic agents group (26%; p=0.0012)
Vol 371 May 24, 2008

21. Intensive Insulin Therapy and Mortality Among Critically Ill Patients
Favors IIT Favors Control
Mixed ICU
Medical ICU
Results of a recent meta-analysis that included the NICE-SUGAR study. Overall no difference… but Surgical patients appear to benefit from tight glycemic control.
Surgical ICU
ALL ICU
Griesdale DE, et al. CMAJ. 2009;180(8):

22. No. Events/Total No. Patients
Intensive Insulin Therapy and Hypoglycemic Events in Critically Ill Patients
No. Events/Total No. Patients
Study
IIT
Control
Risk ratio (95% CI)
Van den Berghe et al
39/765
6/783
6.65 ( )
Henderson et al
7/32
1/35
7.66 ( )
Bland et al
1/5
1.00 ( )
111/595
19/605
5.94 ( )
Mitchell et al
5/35
0/35
11.00 ( )
Azevedo et al
27/168
6/169
4.53 ( )
De La Rosa et al
21/254
2/250
10.33 ( )
Devos et al
54/550
15/551
3.61( )
Oksanen et al
7/39
1/51
9.15 ( )
Brunkhorst et al
42/247
12/290
4.11( )
Iapichino et al
8/45
3/45
2.67 ( )
Arabi et al
76/266
8/257
9.18 ( )
Mackenzie et al
50/121
9/119
5.46 ( )
NICE-SUGAR
206/3016
15/3014
13.72 ( )
Overall
654/6138
98/6209
5.99 ( )
Hypoglycemic Events
Favors IIT Favors Control
Canadian meta-analysis– tight glycemic control is associated with a six-fold increased risk of hypoglycemia
0.1 1 10
Reproduced with permission from Griesdale DE, et al. CMAJ. 2009;180(8):
Risk Ratio (95% CI)

23. Is Hypoglycemia Life Threatening?
[Devos.CurrOpin ClinNutr.2007/p206/ c2/line 40-46, p207/ c1/line 1-4]
Strategies for Preventing Hypoglycemia
These recent studies and meta-analysis bring up 2 questions…

24. Blood Glucose During Hospitalization and Incidence of Death Within 2 Years
[Svensson.EurHeartJ. 2005/p1260/Fig 2]
Lowest blood glucose recorded during hospital stay
≤3.0 mmol/L or 55 mg/dL
n+44; 20 deaths
mmol/L or mg/dL
n=364; 101 deaths
≥6.6 mmol/L or ≥120 mg/dL
n=276; 107 deaths
( )
-3.5
-2.5
-1.5
-.5 .5
1.5
2.5
3.5
Referent
( )
This study evaluated the associations between glycometabolic parameters at admission and during hospitalization and 2-year all-cause mortality risk in an unselected cohort of consecutive patients with diabetes admitted for unstable angina or non-Q-wave myocardial infarction to a university hospital during
For the 684 patients with blood glucose data during hospitalization available, 44 patients had at least 1 documented hypoglycemic event with glucose documented ≤3.0 mmol/L (≤55 mg/dL), 364 had an intermediate glucose value ( mmol/L or mg/dL), and 276 had persistent hypoglycemia with the lowest glucose documented ≥6.6 mmol/L (or 120 mg/dL).
Compared with the intermediate group, both the lowest and the highest groups had significantly higher adjusted 2-year mortality using a model that included on-arrival blood glucose as a covariate (HR, 1.93; 95% CI, ; HR, 1.48; 95% CI, , respectively).
Svensson AM et al. Eur Heart J :

25. Severe Hypoglycemia in Critically Ill Patients Associated With Increased Risk of Mortality60 50 40
Mortality Rate, % 30 20 10
This study was a retrospective database review, including a case-control analysis that matched each patient with severe hypoglycemia with 3 controls. It included 102 patients with at least 1 episode of severe hypoglycemia extracted from a series of 5365 medical, surgical, and cardiac patients admitted consecutively between October 1, 1999, and June 15, A program of tight glycemic control was implemented on February 1, 2003; 2666 patients were treated before and 2699 after this date.
Multivariable logistic regression analysis identified diabetes, septic shock, renal insufficiency, mechanical ventilation, severity of illness, and treatment in the tight glycemic control period as independent risk factors for the development of severe hypoglycemia (defined as glucose <40 mg/dL).
Mortality was 55.9% among the 102 patients with severe hypoglycemia and 39.5% among the 306 controls (P=.006).
Multivariable logistic regression analysis identified severe hypoglycemia as an independent predictor of mortality for the entire cohort (odds ratio, 2.28; 95% CI, ; P=.008). SH
Controls
No SH
Severe hypoglycemia (<40 mg/dL) was associated with an increased risk of mortality (OR, 2.28; 95% CI, ; P=.0008)
Krinsley JS, Grover A. Crit Care Med. 2007;35(10):

26. Blood Glucose & Post-AMI Outcomes A U-Shaped Relationship?
Title
Subtitle
Blood Glucose & Post-AMI Outcomes A U-Shaped Relationship?
P < for each endpoint
Pinto DS, et al. J Am Coll Cardiol. 2005;46: 26

27. Mean Glucose & In-Hospital Mortality in 16,871 Patients with AMI
(Reference: Mean BG mg/dl)
Investigators evaluated 16,871 acute myocardial infarction (MI) patients hospitalized from January 2000 to December Using logistic regression models and C indexes, 3 metrics of glucose control (mean glucose, time-averaged glucose, hyperglycemic index), each evaluated over 3 time windows (first 24 hours, 48 hours, entire hospitalization), were compared with admission glucose for their ability to discriminate hospitalization survivors from nonsurvivors. Models were then used to evaluate the relationship between mean glucose and in-hospital mortality.
In unadjusted analysis, higher mean hospitalization glucose was strongly associated with higher in-hospital mortality. As shown in the figure on the left, when mean hospitalization glucose was analyzed in increments of 10 mg/dL, there was a clear J-shaped relationship between glucose values and mortality rates. Although in the normal glucose range, patients without recognized diabetes had a lower mortality rate than patients with diabetes, their risk increased much more steeply at higher glucose levels, surpassing the risk of patients with diabetes at approximately 130 mg/dL. After multivariable adjustment, the nature of these relationships persisted. As shown in the figure on the right, higher mean hospitalization glucose continued to be strongly associated with higher in-hospital mortality. There was a statistically significant, gradual increase in the odds of in-hospital mortality with each 10-mg/dL incremental rise in mean hospitalization glucose levels above the threshold of 120 mg/dL. The odds of death associated with higher mean glucose rose steeply in patients without recognized diabetes once mean glucose levels exceeded 120 mg/dL.
Measures of persistent hyperglycemia were better predictors of mortality than was admission glucose. Mean hospitalization glucose appears to be the most practical metric of hyperglycemia-associated risk in patients with acute MI.
Kosiborod M et al. Circulation 2008:117:1018

28. Hypoglycemia and Cardiovascular Events
Tachycardia and high blood pressure
Myocardial ischemia
Silent ischemia, angina, infarction
Cardiac arrhythmias
Transiently prolonged corrected QT interval,
Increased QT dispersion
Sudden death
Why is hypoglycemia bad?
We MUST avoid hypoglycemia NOT ONLY because acute neuroglycopenia, AMS and risk of seizures, but due to CV complications.
Wright RJ, Frier BM, Diabetes Metab Res Rev 2008; 24: 353–363.

29. Strategies for Preventing Hypoglycemia in the ICU
[Devos.CurrOpin ClinNutr.2007/p206/ c2/line 40-46, p207/ c1/line 1-4]
Better protocols and systems to implement insulin protocols
Less aggressive BG targets (AACE/ADA Guidelines)
Improved glucose monitoring devices to analyzed frequent and accurate real-time CGM
Inpatient hyperglycemia teams
SO, WHAT CAN we DO?

30. AACE/ADA Recommended Target Glucose Levels in ICU Patients
ICU setting:
Starting threshold of no higher than 180 mg/dL
Once IV insulin is started, the glucose level should be maintained between 140 and 180 mg/dL
Lower glucose targets ( mg/dL) may be appropriate in selected patients  
Targets <110 mg/dL or >180 mg/dL are not recommended
Based on the high rate of hypoglycemia and no difference in mortality in major trials, and the results of NICE –SUGAR that reported increased mortality… NEW TASK FORCE.
The slide shows the recommendations for target glucose levels in critically ill patients in the intensive care setting, which were released on May 8, 2009, by the American Association of Clinical Endocrinologists and the American Diabetes Association, and published online in the June issues of Endocrine Practice and Diabetes Care. They include the following:
Insulin therapy should be initiated for treatment of persistent hyperglycemia, starting at a threshold of no greater than 180 mg/dL.
Once insulin therapy has been started, a glucose range of 140 to 180 mg/dL is recommended for the majority of critically ill patients.
Intravenous insulin infusions are the preferred method for achieving and maintaining glycemic control in critically ill patients.
Validated insulin infusion protocols with demonstrated safety and efficacy, and with low rates of occurrence of hypoglycemia, are recommended.
With IV insulin therapy, frequent glucose monitoring is essential to minimize the occurrence of hypoglycemia and to achieve optimal glucose control.
Recommended
Acceptable
Not recommended
<110
>180
Moghissi ES, et al; AACE/ADA Inpatient Glycemic Control Consensus Panel. Endocr Pract. 2009;15(4).
Moghissi ES, Korytkowski MT, Dinardo M, et al; AACE/ADA Inpatient Glycemic Control Consensus Panel. American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on Inpatient Glycemic Control. Endocr Pract. 2009;15(4). Accessed May 18, 2009. 30

31. AACE/ADA Target Glucose Levels in Non–ICU Patients
Non–ICU setting:
Premeal glucose targets <140 mg/dL
Random BG <180 mg/dL
To avoid hypoglycemia, reassess insulin regimen if BG levels fall below 100 mg/dL
Occasional patients may be maintained with a glucose range below and/or above these cut-points
For the majority of noncritically ill patients treated with insulin, the premeal blood glucose (BG) target should generally be less than 140 mg/dL in conjunction with random BG levels less than 180 mg/dL, provided these targets can be safely achieved.
To avoid hypoglycemia, consideration should be given to reassessing the insulin regimen if BG levels decline below 100 mg/dL.
Modification of the regimen is necessary when BG values are <70 mg/dL, unless the event is easily explained by other factors (such as a missed meal).
More stringent targets may be appropriate in stable patients in whom tight glycemic control was achieved previously. Less stringent targets may be appropriate in terminally ill patients or patients with severe comorbidities.
Hypoglycemia is defined as any BG level <70 mg/dL. Severe hypoglycemia in hospitalized patients has been defined by many clinicians as BG <40 mg/dL, although this value is lower than the approximate 50 mg/dL level at which cognitive impairment begins in normal persons.
Scheduled subcutaneous administration of insulin, with basal, nutritional, and correction components, is the preferred method for achieving and maintaining glucose control. Prolonged treatment with sliding-scale insulin as the sole regimen is discouraged. Noninsulin antihyperglycemic agents are not appropriate in most hospitalized patients who require treatment for hyperglycemia.
Hypoglycemia = BG <70 mg/dL
Severe hypoglycemia = BG <40 mg/dL
Moghissi ES, et al; AACE/ADA Inpatient Glycemic Control Consensus Panel. Endocr Pract. 2009;15(4).
Moghissi ES, Korytkowski MT, Dinardo M, et al; AACE/ADA Inpatient Glycemic Control Consensus Panel. American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on Inpatient Glycemic Control. Endocr Pract. 2009;15(4). Accessed May 18, 2009. 31

32. Methods For Managing Hospitalized Persons with Diabetes
Title
Subtitle
Methods For Managing Hospitalized Persons with Diabetes
Continuous Variable Rate IV Insulin Drip Surgery, NPO, Unstable, MI, DKA, Hyperglycemia, Steroids, Gastroparesis, Delivery, etc
Basal / Bolus Therapy (MDI) when eating

33. The Ideal IV Insulin Protocol
Title
Subtitle
The Ideal IV Insulin Protocol
Easily ordered (signature only or preferably nurse mandated)
Effective (Gets to goal quickly)
Safe (Minimal risk of hypoglycemia)
Easily implemented
Able to be used hospital wide

34. Essentials of a good IV Insulin Algorithm
Title
Subtitle
Essentials of a good IV Insulin Algorithm
Easily implemented by nursing staff
Able to seek BG range via:
- Hourly BG monitoring
- Adjusts to the insulin sensitivity
of the patient

35. Various Protocols Exist
Title
Subtitle
Various Protocols Exist
Atlanta Multiplier Method
Van den Berghe (studied in critical care setting)
Portland Protocol (used in surgical setting)
Markovitz (studied in postoperative heart surgery patients)
Yale Protocol (studied in medical intensive care setting)
Various Protocols Exist
A number of protocols have been published for the administration of continuous insulin infusion. The use of standardized protocols is associated with improved glycemic control and low rates of hypoglycemia.

36. Practical Closed Loop Insulin Delivery: Multiplier Method
A System for the Maintenance of Overnight Euglycemia and the Calculation of Basal Insulin Requirements in Insulin-Dependent Diabetics
1/slope = Multiplier = 0.02 6 5 4
Insulin Rate (U/hr) 3 2 1
100
200
300
400
Glucose (mg/dl)
NEIL H. WHITE, M.D., DONALD SKOR, M.D., JULIO V. SANTIAGO, M.D.;Ann Int Med 1982 ;97:

37. Continuous Variable Rate IV Insulin Drip Atlanta Multiplier Method
Title
Subtitle
Continuous Variable Rate IV Insulin Drip Atlanta Multiplier Method
Starting Rate Units / hour = (BG – 60) x 0.02
where BG is current Blood Glucose
and is the multiplier
Check glucose every hour and adjust drip
Adjust Multiplier to keep in desired glucose
target range (90 to 120 in ICU; 100 to 140 on floor)

38. Multiplier Principles
Insulin
Units / Hour
Glucose
mg/ dl
Davidson et al, Diabetes Care 28(10): , 2005

41. Ideal Solution Computer directed insulin infusion
Title
Subtitle
Ideal Solution
Computer directed insulin infusion
Complexity is moved to the computer
Standardization is achieved
Hypoglycemia is minimized
Davidson et al, Diabetes Care 28(10): , 2005

42. Computer-Guided Vs. Standard Column-Based Insulin Regimens
Study Aim: To determine differences in glycemic control between treatment with a computer-guided algorithm (Glucommander) and a standard paper-form algorithm in critically ill patients in the ICU
Design: Multi-center, prospective, randomized trial in hyperglycemic patients admitted to a medical ICU
Primary outcome: Differences in BG control
Secondary outcomes: Number of hypoglycemic (BG <60 mg/dL and < 40 mg/dl) and hyperglycemic events (BG >200 mg/dL), ICU and hospital length of stay
To investigate if “better or different algorithms” may not be the answer… we recently completed a Comparison study of Insulin Infusion Protocols in the ICU: Computer-Guided (Glucommander) Vs. Standard Column-Based (paper-form) Insulin Regimens.
Presented at the ADA 2008 meeting.
Newton CA et al. Diabetes 57 (Suppl. 1) 136A, 2008.

43. Glucommander vs. Standard Mean Glucose Values
Mean Glucose Maintained once Target Achieved
Glucommander = ± 9 mg/dL
Standard = ± 18 mg/dL
Glucommander lower BG (P<0.0001) but not sure if the difference is clinical significant (based on recent large RCT)
* p <
Newton CA et al. Diabetes 57 (Suppl. 1) 136A, 2008. 43

44. Glucommander vs. Standard
% of Glucoses Maintained within Target Achieved
Glucommander = 68.6%
Standard = 46.4%*
Glucommander had less BG variability (fluctuations) than paper form – may be an important point.
* p <
Newton CA et al. Diabetes 57 (Suppl. 1) 136A, 2008. 44

45. % of PATIENTS with LOWEST BG < 40 mg/dL
BGmean
All GlucommanderTM 1.1%
G+TM
G+TM SICU
Other Tight-Control NICE-SUGAR GlucommanderTM

46. Strategies for Preventing Hypoglycemia
Algorithm 1
Algorithm 2
Algorithm 3
Algorithm 4
BG (mg/dL)
Units/hr BG
(mg/dL)
<60 = Hypoglycemia (See below for treatment)
<70
Off 70 -
109
0.2
0.5 1
1.5
110
119 2 3
120
149 5
150
179 4 7
180
209 9
210
239 6 12
240
269 8 16
270
299 10 20
300
329
Reduce insulin rate or hold insulin infusion at a higher BG concentration
This is an example of a paper-form protocol. High rate of BG < 60 mg/dl -- The reason is that we targeted a BG between mg/dl. Both protocols did not reduce or held insulin until the BG was < 70 mg/dl. 24
330 -
359 4
330 -
359 8
330 -
359 14
>330 28
>360 6
>360 12
>360 16
Newton CA et al. Diabetes 57 (Suppl. 1) 136A, 2008.

47. Events Triggering Hospital Hypoglycemia
Transportation off ward, causing meal delay
Failure to measure blood glucose before insulin doses
New NPO status
Interruption of
IV dextrose therapy
Total parenteral nutrition
Enteral feedings
Continuous venovenous hemodialysis
NON_ICU
The slide lists events that can trigger in-hospital hypoglycemia.
All of the events, except for failure to measure blood glucose before insulin doses, result from decreased caloric intake related to illness or hospital routine.
Braithwaite SS, et al. Endocr Pract. 2004;10(suppl 2):89-99.
Braithwaite SS, Buie MM, Thompson CL, et al. Hospital hypoglycemia: not only treatment but also prevention. Endocr Pract. 2004;10(suppl 2):89-99.

48. Features Increasing the Risk of Hypoglycemia in an Inpatient Setting
Advanced age
Renal failure
Liver disease
Concurrent illness (cerebral vascular accident, congestive heart failure, shock, sepsis)
Ventilator use
Concurrent medications (-blockers, quinolones, epinephrine)
Among the patient risk factors for hypoglycemia are advanced age, renal failure, liver disease, concurrent illness (eg, cerebral vascular accident, congestive heart failure, shock, sepsis), ventilator use, and use of concurrent medications (eg, β-blockers, quinolones, steroids, epinephrine).
D’Hondt NJ. Diabetes Spectrum. 2008;21(4):

49. Benefits of a Nurse-Mandated Protocol
Title
Subtitle
Benefits of a Nurse-Mandated Protocol
All patients are screened and treated the same way
Standardization can be achieved
Modification of the protocols can easily be done based on outcomes and analysis of the data

50. Patient Presents With Hyperglycemia
Title
Subtitle
Patient Presents With Hyperglycemia
Previously diagnosed DM
Diabetic ketoacidosis or hyperglycemic crisis follow DKA protocol
No previous diagnosis of DM and BG
> 140 mg/dL
Modification of therapy to keep BG at goal
BG is > 110 mg/dL for a critically ill patient; notify physician for initiation of IV insulin therapy
Begin BG testing
BG is > 140 mg/dL for noncritically ill patient, notify physician for initiation of subcutaneous therapy
All patients with hyperglycemia should have an HbA1C drawn
to aid in transition and discharge therapy

51. Methods of Screening for Hyperglycemia
Title
Subtitle
Methods of Screening for Hyperglycemia
Finger stick blood glucose on admission or use of the glucose done on the biochemical profile
If glucose >110 mg/dL fasting or >140 mg/dL random, place in appropriate protocol and continue monitoring
Draw Hemoglobin A1C for help in deciding who needs transition from IV to SC insulin and what treatment is needed at home, including insulin.
Hyperglycemia in Patients With Undiagnosed Diabetes
New hyperglycemia was defined as an admission or in-hospital fasting glucose level of 126 mg/dL (7 mmol/L) or more or a random blood glucose level of 200 mg/dL (11.1 mmol/L) or more on 2 or more determinations. Hyperglycemia was present in 38% of patients admitted to the hospital, of whom 26% had a known history of diabetes, and 12% had no history of diabetes before admission.
Newly discovered hyperglycemia was associated with a higher in-hospital mortality rate (16%) compared with patients with a history of diabetes (3%) and patients with normoglycemia (1.7%; both P < 0.01).
In addition, new hyperglycemic patients had longer hospital stays and a higher admission rate to an intensive care unit, and were less likely to be discharged to home, frequently requiring transfer to a transitional care unit or nursing home facility.
The results indicate that in-hospital hyperglycemia is a common finding and represents an important marker of poor clinical outcome and mortality in patients with and without a history of diabetes. Patients with newly diagnosed hyperglycemia had a significantly higher mortality rate and a lower functional outcome than patients with a known history of diabetes or normoglycemia.
1. Umpierrez GE, Isaacs SD, Bazargan N, et al. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab. 2002;87:

54. Results of Nurse-Mandated Protocol in CV Patients
Title
Subtitle
Results of Nurse-Mandated Protocol in CV Patients
~2000 CV surgery patients have been studied
On IV insulin BG stabilized at <120 mg/dL in a mean of 3 hours
IV insulin was continued for an average of 37 hours
98% were controlled so that no BG was >200 mg/dL in the 48 hours following surgery
2% had transient BG <50 mg/dL; 0% <40 mg/dL
The mean for all BG in all patients was 107 mg/dL
Davidson PC et al. J Diabetes Sci and Technol. 2008; 2(3): 54

55. Average BG’s ± SD of All Glycemic Protocol Runs (n = 470)
Title
Subtitle
Average BG’s ± SD of All Glycemic Protocol Runs (n = 470)

56. Managed by Anesthesiology in Operating Room
Title
Subtitle
Transition to SubQ
Managed by Anesthesiology in Operating Room
SubQ Basal-Bolus
Glucommander
hours

57. Transition from Glucommander to Basal-Bolus Insulin
Glargine and Aspart
Basal: Multiplier * 500; CIR: 0.5 / Multiplier; Correction Factor: 1.7 / Multiplier
n=209
Blood Glucose (mg/dl)
Hours after IV insulin
Last GM
Bedtime
Breakfast
Breakfast
Breakfast
Lunch
Dinner
3:00AM
Lunch
Bedtime
Dinner
3:00AM
Bedtime
Lunch
Dinner
3:00AM

58. CVS Hyperglycemia Protocol Piedmont Hospital 2006
Title
Subtitle
CVS Hyperglycemia Protocol Piedmont Hospital 2006
Reduced post-op length of stay: 0.8 days
ICU cost per day: $1,244.99
CVS at Piedmont per year: 998
Annual savings: 0.8 * $1,245 * 998 = $994,000
Sites in database of Society of Thoracic Surgeons: 860
Projected total national savings: $855 million

59. Converting to SC insulin
Title
Subtitle
Converting to SC insulin
If More than 0.5 u/hr IV insulin required with normal BG, start long-acting insulin (glargine)
Exception: if no prior DM and normal A1C, may not need SC insulin
Must start SC insulin at least 1 to 2 hours before stopping IV insulin
Some centers start long-acting insulin on initiation of IV insulin or the night before stopping the drip

60. Total Intravenous vs. Subcutaneous 24-hour Insulin Requirements, units
Title
Subtitle
Intravenous Insulin Infusion Under Basal Conditions Correlates Well With Subsequent Subcutaneous Insulin Requirement
Total Intravenous vs. Subcutaneous 24-hour Insulin Requirements, units
275
250
225
200
175
150
125
100 75 50 25
Units SQ
Intravenous Insulin Infusion Under Basal Conditions Correlates Well With
Subsequent Subcutaneous Insulin Requirement 25 50 75
100
125
150
175
200
225
250
275
Units IV
Hawkins et al. Endocr Pract. 1995;1:385–389.

61. Glulisine Glulisine Glulisine
Basal/Bolus Treatment Program with Rapid-acting and Long-acting Analogs
Breakfast
Lunch
Dinner
Aspart, Aspart, Aspart,
Lispro Lispro Lispro or or or
Glulisine Glulisine Glulisine
Plasma insulin
Glargine or
Detemir
4:00
8:00
12:00
16:00
20:00
24:00
4:00
8:00
Time

62. Converting from IV to SC insulin
Title
Subtitle
Converting from IV to SC insulin
Establish 24 hr Insulin Requirement
Extrapolate from average over last 4 hr if stable
Give One-Half Amount As Basal
Give One-Half Amount As Total Bolus
Give post meal based on portion of food consumed or
Give 1.5 units Rapid-acting for every CHO consumed
Monitor a.c. tid, hs, and 3 am
Correction Bolus for All BG >140 mg/dl

63. Initiating SC Basal Bolus
Starting total dose = 0.5 x wgt. in kg
Wt. is 100 kg; 0.5 x 100 = 50 units
Basal dose (glargine) = 50% of starting dose at HS
0.5 x 50 = 25 units at HS
Bolus doses (rapid analog) = 50% of starting dose
0.5 x 50 = 25 divided by 3 = ~8 units pc (tid)
Correction bolus = (BG - 100)/ CF, where CF = 1700/total daily dose; CF = 30

64. Case #1 Fifty-eight y/o male with: T2DM x 8 years
Shortness of breath lasting ~48 hours
Substernal fullness (oppressive feeling) OFF/ON for 4 hours
T2DM x 8 years
Metformin plus SU plus TZD (maximum doses)
CAD with history of MI 3 years ago
2 vessel stent placements following MI
Dual oral antiplatelet therapy
HTN x 8 years
ACE inhibitor, β-blocker, furosemide
Dyslipidemia x 8 years
Statin
Patient History
Key Point: This is a case study of a 58-year-old man who is presenting to the local emergency department (ED) with chief complaints of shortness of breath and pedal edema.
SU, sulfonylurea; TZD, thiazolidinedione; CAD, coronary artery disease; HTN, hypertension; ACE, angiotensin converting enzyme; BMI, body mass index.

65. Rabbit 2 Trial: Treatment Success With Basal-Bolus vs
Rabbit 2 Trial: Treatment Success With Basal-Bolus vs. Sliding Scale Insulin
300
Sliding-scale
Basal-bolus
Hypoglycemia rate:
280
260
240
Basal Bolus Group:
BG < 60 mg/dL: 3%
BG < 40 mg/dL: none
SSRI:
BG < 40 mg/dL: none
220
BG, mg/dL
200
180
160
140
120
100
Admit 1 2 3 4 1 2 3 4 5 6 7
Key Point: A significant number of patients in the basal-bolus group reached the BG target of <140 mg/dL. Blood glucose levels significantly improved in patients who had failed sliding-scale insulin delivery and were switched to the basal-bolus regimen.
With the BG target of <140 mg/dL, 66% (43 patients) in the basal-bolus group reached the target, while only 38% (25 patients) in the sliding-scale insulin delivery group met this goal.
Fourteen percent (9 patients) of the patients treated with sliding-scale insulin delivery remained severely hyperglycemic, defined as BG >240 mg/dL, despite dose maximization. Glycemic control improved in these patients once they were switched to the basal-bolus regimen.
Two patients in each group had hypoglycemia (defined as BG <60 mg/dL). No cases of severe hypoglycemia (defined as BG <40 mg/dL) were reported.
Days of Therapy
Persistent hyperglycemia (BG>240 mg/dl) is common (15%) during SSI therapy
Umpierrez GE, et al. Diabetes Care. 2007;30(9):
Umpierrez GE, Smiley D, Zisman A, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial). Diabetes Care. 2007;30(9):

66. Rabbit 2 Trial: Changes in Glucose Levels With Basal-Bolus vs
Rabbit 2 Trial: Changes in Glucose Levels With Basal-Bolus vs. Sliding Scale Insulin
240
220 a
200 a a b b
180 b
BG, mg/dL b
Sliding-scale
160
140
Basal-bolus
120
100
Admit 1 2 3 4 5 6 7 8 9 10
Key Point: Patients randomized to basal-bolus therapy achieved better glycemic control compared with those receiving sliding-scale insulin delivery in a hospitalized, non–ICU setting.
This multicenter, prospective, open-label, randomized study enrolled 130 nonsurgical, insulin-naïve patients with a known history of diabetes for >3 months, admitted to medical general services with a blood glucose level between 140 and 400 mg/dL. Patients were randomly assigned to receive either sliding-scale regular insulin (SSRI; n=65) 4 times daily or a basal-bolus regimen with insulins glargine and glulisine (n=65). The goal of insulin therapy was to maintain fasting and premeal blood glucose levels <140 mg/dL while avoiding hypoglycemia.
Compared with the basal-bolus group, patients who received sliding-scale insulin delivery had higher mean fasting glucose (165 ± 41 vs 147 ± 36 mg/dL, respectively, P<.01), mean random glucose (189 ± 42 vs 164 ± 35 mg/dL, respectively, P<.001), and mean glucose (193 ± 54 vs 166 ± 32 mg/dL, respectively, P<.001) during the hospital stay.
The overall BG difference between treatment groups was 27 mg/dL (P<.01), with a mean daily BG difference ranging from 23 to 58 mg/dL during days 2 through 6 of therapy (P<.01).
aP<.05.
Days of Therapy
bP<.05.
Sliding scale regular insulin (SSRI) was given 4 times daily
Basal-bolus regimen: glargine was given once daily; glulisine was given before meals.
0.4 U/kg/d x BG between mg/dL
0.5 U/kg/d x BG between mg/dL
Umpierrez GE, et al. Diabetes Care. 2007;30(9):
Umpierrez GE, Smiley D, Zisman A, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial). Diabetes Care. 2007;30(9):

67. Correction Bolus Formula
Current BG - Ideal BG
Glucose Correction factor
Example:
Current BG: mg/dl
Ideal BG: mg/dl
Glucose Correction Factor: 30 mg/dl 30
= 5.0u

69. Categories of “Never” Events
Surgical
eg, Amputation of incorrect body part
Product/device
eg, Use of contaminated device
Patient protection
eg, Inability to prevent a patient suicide
Care management
eg, Medication error leading to hypoglycemic event
Environmental
eg, Patient fall during hospital stay
Criminal
eg, Impersonation of a health care provider
“Never” events can be related to surgical procedures, product/device, patient protection, care management, environment, and crime
Surgical events include incorrect surgery being done, or surgery performed on the wrong body part or patient
Product or device events involve patient death or disability as a result of contaminated drugs or devices, and the occurrence of intravascular embolism
Patient protection events include patient suicide or disappearance of a patient resulting in death or serious disability
Examples of care management events include patient death/serious disability related to a medication error (eg, wrong drug, dose, patient, time, rate, preparation, or route of administration); and death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a health care facility
Environmental events include burns, falls, electric shock, and the use of restraints that result in patient death or serious disability
Criminal events range from abduction and assault to the ordering of patient care by someone impersonating a licensed health care provider
National Quality Forum. Serious Reportable Events in Healthcare, 2006 Update: Executive Summary. Washington, DC: NQF; 2007.
Reference
National Quality Forum. Serious Reportable Events in Healthcare, 2006 Update: Executive Summary.
Washington, DC: National Quality Forum; 2007.

70. Protocol for Treatment of Hypoglycemia
Any BG <60 mg/dl: D50 = (100-BG) x 0.4 ml IV
Recheck in 15 minutes and retreat if needed
If eating, may use 15 gm of rapid CHO
Do Not Hold Insulin When BG Normal

71. Hospital-Acquired Conditions: “Reasonably Preventable” Events
Foreign object left in patient postsurgery
Air embolism
Blood incompatibility
Falls and trauma
Pressure ulcers
Vascular catheter- related infection
Catheter-related urinary tract infection
Manifestations of poor glycemic control
Certain orthopedic surgical site infections
Surgical site infection-mediastinitis following CABG
Bariatric surgical site infections
Deep vein thrombosis or pulmonary embolism after orthopedic procedures
Hospital-acquired conditions (HACs) are defined as “reasonably preventable” with the implementation of evidence-based guidelines
HACs include the following:
Foreign object left in patient postsurgery
Air embolism
Blood incompatibility
Falls and trauma
Pressure ulcers
Vascular catheter-related infection
Catheter-related urinary tract infection
Manifestations of poor glycemic control
Certain orthopedic surgical site infections
Bariatric surgical site infections
Surgical site infection-mediastinitis following CABG
Deep vein thrombosis or pulmonary embolism after orthopedic procedures
Department of Health and Human Services: Centers for Medicare and Medicaid Services. Fed Regist. 2008;73:
Reference
Department of Health and Human Services: Centers for Medicare and Medicaid Services. Fed Regist. 2008;73:

72. TPN or Enteral Feedings
Determine insulin requirement via IV Insulin needs
For TPN, add insulin to TPN bag with correction SC every 4 to 6 hours
For enteral feedings, give Glargine or Detemir every 12 hours or NPH every 8 hours or Regular every 6 hours with correction SC every 4 to 6 hours.

73. Hospital Diabetes Plan What Can We Do For Patients Admitted To Hospital?
Pathway Protocols For All Hyperglycemia and Diabetes Patients
Finger Stick BG ac qid on ALL Admissions with BG >140 mg/dL or history of DM or high risk (ICU, Cardiac, Vascular, CVA, Steroids, etc)
Check Hemoglobin A1C in all hyperglycemic patients

74. Hospital Diabetes Plan Protocol for Insulin in Hospitalized Patient
Treat Any Patient With BG >110 or >140 mg/dl With Insulin
If able to eat and not acutely sick, initiate basal bolus therapy SC
If unable to eat or acutely ill or unable to control, pace on an insulin drip
If known diabetes or A1c >6%, transition patient to basal bolus therapy once BG at goal and stable.

75. Endocrine or Diabetes Consult
Endocrine/Diabetes consult for any of the following reasons:
Glycemic control is not obtained (i.e. BG’s <70 or >140 mg/dl)
At the request of nursing services
At MD request

76. Diabetes Education and Discharge Planning
Diabetes service is contacted for all patients new to SC insulin.
Discharge planning is initiated.
Instruct Patient in Monitoring and Recording See That Patient Has Meter on Discharge
Decide on Case Specific Program for Discharge
Arrange Early F/U with PCP

77. Conclusion Our journey is not over, it has only begun
Title
Subtitle
Conclusion
Our journey is not over, it has only begun
We must normalize glucose in all hospital patients
By implementing, assessing, and revising protocols / pathways for hyperglycemic management, we can ultimately achieve this goal of euglycemia