Editorials

New Standards to Reduce Morbidity and Mortality in Hospitalized Patients with Diabetes

Am Fam Physician. 2006 Feb 15;73(4):591-594.

Diabetes has reached epidemic proportions in the United States. This is true whether patients are outpatients or inpatients; diabetes is the fourth most common comorbid condition complicating all hospital discharges. In 1997, diabetes was present in 9.5 percent of all patients discharged from hospitals and in 29 percent of patients undergoing cardiac surgery.1 Diabetes is associated with a two- to four-fold increase in hospitalization rates; its presence increases the length of hospital stays by one to three days, depending on the admission diagnosis. In-hospital hyperglycemia is an important marker of poor clinical outcomes and mortality in patients with or without diabetes.2

Although several organizations have issued guidelines for outpatient management of diabetes, no guidelines have been formulated for inpatient management. The American College of Endocrinology, in collaboration with several other organizations, has developed a consensus statement on inpatient diabetes and metabolic control.3  Because so many groups are involved in the care of hospitalized patients who may experience hyperglycemia, a multidisciplinary group was formed to develop a single set of standards and guidelines; the recommendations were cosponsored by the American Association of Diabetes Educators, the American Diabetes Association, the American Heart Association, the American Society of Anesthesiologists, the Society of Critical Care Medicine, the Society of Hospital Medicine, the Society of Thoracic Surgeons, the Endocrine Society, and the American College of Cardiology. The rationale for developing guidelines to achieve tight glycemic control in the hospital was based on increasing evidence that metabolic regulation of hyperglycemia translates into improved outcomes in patients with diabetes and in those who develop hyperglycemia in the hospital (see accompanying table410).

Outcomes Associated with Hyperglycemia and Aggressive Insulin Therapy in Hospitalized Patients

Hyperglycemia

Complications of MI4

Complications of stroke5

Complications of vascular and cardiac surgery6

Mortality in critically ill patients7

Mortality after coronary bypass surgery

Aggressive insulin therapy

Improved cardiac surgery outcomes8; mortality risk reductions of 50 percent or greater have been observed in patients treated with insulin infusions for the first three postoperative days.

Improved ICU outcomes810 (e.g., 34 percent reduction in hospital mortality rates, 46 percent decrease in rates of sepsis, 41 percent decrease in rates of acute renal failure, 50 percent reduction in transfusions, 44 percent reduction in critical-illness polyneuropathy)9

Improved post-MI outcomes4 (e.g., 28 percent improvement in long-term survival rates in diabetic patients with acute MI)

Reductions in infection rates, intubation times, length of hospital stays, and cost


MI = myocardial infarction; ICU = intensive care unit.

Information from references 4 through 10.

Outcomes Associated with Hyperglycemia and Aggressive Insulin Therapy in Hospitalized Patients

View Table

Outcomes Associated with Hyperglycemia and Aggressive Insulin Therapy in Hospitalized Patients

Hyperglycemia

Complications of MI4

Complications of stroke5

Complications of vascular and cardiac surgery6

Mortality in critically ill patients7

Mortality after coronary bypass surgery

Aggressive insulin therapy

Improved cardiac surgery outcomes8; mortality risk reductions of 50 percent or greater have been observed in patients treated with insulin infusions for the first three postoperative days.

Improved ICU outcomes810 (e.g., 34 percent reduction in hospital mortality rates, 46 percent decrease in rates of sepsis, 41 percent decrease in rates of acute renal failure, 50 percent reduction in transfusions, 44 percent reduction in critical-illness polyneuropathy)9

Improved post-MI outcomes4 (e.g., 28 percent improvement in long-term survival rates in diabetic patients with acute MI)

Reductions in infection rates, intubation times, length of hospital stays, and cost


MI = myocardial infarction; ICU = intensive care unit.

Information from references 4 through 10.

The consensus panel reviewed research with the original investigators to formulate standards for diabetes management in the hospital and to suggest techniques by which these goals and targets may be achieved. The data clearly show that all patients, especially those previously undiagnosed with diabetes, benefit from intensive management of hyperglycemia with insulin. The panel concluded that patients in intensive care units should have a target glycemic level of 110 mg per dL (6.1 mmol per L) and that medical and surgical patients should have a target preprandial level of 110 mg per dL and a maximal level of 180 mg per dL (10.0 mmol per L).

Insulin, whether administered intravenously or subcutaneously, was determined to be the primary means of effective glycemic control in the hospital setting. The use of standardized protocols for continuous intravenous insulin therapy is associated with improved glycemic control and low rates of hypoglycemia; the use of sliding scales is discouraged.

The next great challenge will be implementation of these standards. Hospital systems will have to change to achieve the goals defined above. Hospital- and ward-wide protocols for administration and monitoring of blood glucose levels and insulin infusions will be needed, as will protocols for risk management for hypoglycemia. Furthermore, a broad base of medical and surgical specialists must participate if we are to be successful in reducing diabetic inpatient mortality and morbidity rates; greater integration of care across units and the support of nursing and pharmacy staff will be needed. Clearly, there is a role for the family physician in the implementation and coordination of these guidelines.

The occurrence of significant hyperglycemia in the hospital will require close follow-up after discharge. In patients with previously diagnosed diabetes and an elevated A1C level, the preadmission diabetes care plan requires revision. In patients without previously diagnosed diabetes, the differentiation between hospital-related hyperglycemia and undiagnosed diabetes requires follow-up testing (e.g., fasting blood glucose measurements, two-hour oral glucose tolerance tests) once patients are metabolically stable. Outpatient diabetes self-management training is critical to minimize the risk of future complications.

The Author

ALAN J. GARBER, M.D., Ph.D., is professor in the Departments of Medicine, Molecular and Cellular Biology, and Biochemistry and Molecular Biology at Baylor College of Medicine, Houston, Texas.

Address correspondence to Alan J. Garber, M.D., Ph.D., Baylor College of Medicine, Faculty Center, Suite 1000, 1709 Dryden Rd., BCM-620, Houston, TX 77030. Reprints are not available from the author.

REFERENCES

1. Elixhauser A. Hospitalization in the United States, 1997. Rockville, Md.: Agency for Healthcare Research and Quality, 2000. AHRQ publication 00–0031.

2. Garber AJ, Seidel J, Armbruster M. Current standards of care for inpatient glycemic management and metabolic control: is it time for definite standards and targets?. Endocr Pract. 2004;10(suppl 2):10–2.

3. American College of Endocrinology. American College of Endocrinology consensus statement on guidelines for glycemic control. Endocr Pract 2002;8(suppl 1):5–11. Accessed online January 20, 2006, at: http://www.aace.com/pub/positionstatements.

4. Malmberg K. Role of insulin-glucose infusion in outcomes after acute myocardial infarction: the diabetes and insulin-glucose infusion in acute myocardial infarction (DIGAMI) study. Endocr Pract. 2004;10(suppl 2):13–6.

5. Capes SE, Hunt D, Malmberg K, Pathak P, Gerstein HC. Stress hyperglycemia and prognosis of stroke in non-diabetic and diabetic patients: a systematic overview. Stroke. 2001;32:2426–32.

6. Furnary AP, Wu Y, Bookin SO. Effect of hyperglycemia and continuous intravenous insulin infusions on outcomes of cardiac surgical procedures: the Portland Diabetic Project. Endocr Pract. 2004;10(suppl 2):21–33.

7. Krinsely JS. Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients. Mayo Clin Proc. 2003;78:1471–8.

8. Van der Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med. 2001;345:1359–67.

9. Krinsley JS. Effect of an intensive glucose management protocol on the mortality of critically ill adult patients [published correction appears in Mayo Clin Proc 2005;80:1101]. Mayo Clin Proc. 2004;79:992–1000.

10. Pittas AG, Siegel RD, Lau J. Insulin therapy for critically ill hospitalized patients: a meta-analysis of randomized controlled trials. Arch Intern Med. 2004;164:2005–11.


Copyright © 2006 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions


Article Tools

  • Print page
  • Share this page
  • AFP CME Quiz

Information From Industry

More in Pubmed

Navigate this Article