Patient Self-Management of Diabetes Care in the Inpatient Setting

Abstract

CommentaryEach year people with diabetes account for millions of inpatient days. Many of those patients are on insulin therapy having successfully managed their diabetes in the outpatient setting. Once admitted to the hospital, most have their diabetes care taken over by the admitting team. Patients' knowledge of their diabetes care may be ignored or not assessed. Outpatient physiologic insulin regimens are often replaced with sliding scale insulin given only when blood glucoses are elevated. This has lead well-controlled patients to experience diabetic ketoacidosis or hyperglycemic crisis. 1One particular challenge in the inpatient setting is coordinating blood glucose monitoring, ingestion of food, and insulin administration. Blood glucose monitoring is usually at set times: before meals, at bedtime, and sometimes during the night. Unlicensed assistive personnel or nurses may do this monitoring. Hospital meals may be scheduled at specific times or available as food on demand. Insulin is given by the nurse caring for the patient (or a medication nurse) based on an ordered time. Ideally, blood glucoses should be checked no more than 30 minutes before meals. Rapid-acting insulin should be given 10-15 minutes before the meal and no more than 20 minutes after the first bite of the meal. Although critical to optimizing blood glucose control, the coordination of these activities among 3 different health care team members can be difficult to achieve. In the best situation the activities may be well planned and coordinated; however, hospital nurses can testify to how the best made plans can be quickly derailed by emergent situations. For patients effectively managing their meal-time insulin at home, the lack of coordination can be a particularly frustrating and sometimes a frightening experience, should it ultimately result in profound hypo-or hyperglycemia.Current guidelines from the American Association of Clinical Endocrinologist (AACE), the American Diabetes Association (ADA), and the Endocrine Society are to administer basal, bolus, and correction insulin therapy in the hospital based on the physiologic needs of the patient. 2,3Though this is most often managed by the primary team, the Joint Commission and ADA recommend that patients who are able, be allowed to self-manage their diabetes while hospitalized. 4,5 The American Society of Healthsystem Pharmacists provides some general guidelines from literature reviews. AbstractPatients should be allowed to manage their diabetes in the hospital. Diabetes mellitus is a common and sometimes difficult to control medical issue in hospitalized patients. Oftentimes patients who have been controlling their diabetes well as an outpatient are not allowed to continue this management on the inpatient setting, which can lead to hypo-and hyperglycemia. Involving the patient in his or her diabetes care, including self-management in select patients, may provide a safe and effective way of improving glycemic control and patient satisfaction. This may particularly benefit the dosing ...

15. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2019

“…Diabetes self-management in the hospital may be appropriate for select youth and adult patients (61,62). Candidates include patients who successfully conduct self-management of diabetes at home, have the cognitive and physical skills needed to successfully self-administer insulin, and perform self-monitoring of blood glucose.…”

14. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2018

“…Diabetes self-management in the hospital may be appropriate for select youth and adult patients (53,54). Candidates include patients who successfully conduct selfmanagement of diabetes at home, have the cognitive and physical skills needed to successfully self-administer insulin, and perform self-monitoring of blood glucose.…”

An Evidence-Based Procedure for Self-Management of Medication in Hospital: Development and Validation of the SelfMED Procedure

“…Allowing patients to already self-manage high-risk medication in a controlled environment might ultimately result in a benefit for the patient [ 9 ]. Literature on the treatment of diabetes in hospital even encouraged patients to self-manage their insulin when hospitalized on the condition that this is also monitored by healthcare providers [ 24 , 25 ].…”