Obstacles to optimal management of inpatient hyperglycemia in noncritically ill patients

Abstract

Compelling evidence continues to evolve linking hyperglycemia in hospitalized patients with adverse clinical outcomes. In 2012, The Endocrine Society's clinical practice guidelines for management of hyperglycemia in non-critical care settings were published, and explicit blood glucose targets for noncritically ill patients were recommended. These matched those set by the American Diabetes Association (ADA) in the Standards of Medical Care in Diabetes--2012. Although there are more specific targets for achieving optimal glycemic control in critically ill and noncritically ill inpatients, implementing standardized processes to achieve these goals continues to remain a challenge. This article summarizes these obstacles and emphasizes the quality of care and safety issues (eg, hypoglycemia and insulin errors) that are associated with the management of hyperglycemia in hospitalized patients. The use of intravenous insulin via computerized or manual standardized protocols in critically ill patients has been shown to be effective in achieving glucose control; we focus on the barriers to the appropriate use of subcutaneous insulin in hospitalized patients with noncritical illness. We also elaborate on how to overcome most of these obstacles and the clinical inertia to treat hyperglycemia through focused education and surveillance, and then "re-education," using a multidisciplinary, collaborative approach. Transition from intravenous insulin to subcutaneous insulin, and transition from an inpatient to an outpatient glycemic regimen at the time of discharge, are identified as aspects of management that require extra attention. We also emphasize the need for a multidisciplinary task force responsible for monitoring and enhancing glycemic control practices in the hospital on an ongoing basis.