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Management of Diabetes and Hyperglycemia in Hospitals

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Management of Diabetes and Hyperglycemia in Hospitals Reviews/Commentaries/Position Statements TECHNICAL REVIEW Management of Diabetes and Hyperglycemia in Hospitals 1 5 STEPHEN CLEMENT MD, CDE REBECCA G. SCHAFER, MS, RD, CDE ● Unrecognized diabetes: hyperglycemia 2 6 SUSAN S. BRAITHWAITE, MD IRL B. HIRSCH, MD (fasting blood glucose Ն126 mg/dl or 3 MICHELLE F. MAGEE, MD, CDE ON BEHALF OF THE DIABETES IN HOSPITALS Ն 4 random blood glucose 200 mg/dl) ANDREW AHMANN, MD WRITING COMMITTEE 1 occurring during hospitalization and ELIZABETH P. SMITH, RN, MS, CANP, CDE confirmed as diabetes after hospitaliza- tion by standard diagnostic criteria, but unrecognized as diabetes by the treat- ing physician during hospitalization. iabetes increases the risk for disor- cemia in hospitals, with particular focus ● Hospital-related hyperglycemia: hyper- ders that predispose individuals to on the issue of glycemic control and its glycemia (fasting blood glucose Ն126 D hospitalization, including coronary possible impact on hospital outcomes. mg/dl or random blood glucose Ն200 artery, cerebrovascular and peripheral The scope of this review encompasses mg/dl) occurring during the hospital- vascular disease, nephropathy, infection, adult nonpregnant patients who do not ization that reverts to normal after hos- and lower-extremity amputations. The have diabetic ketoacidosis or hyperglyce- pital discharge. management of diabetes in the hospital is mic crises. generally considered secondary in impor- For the purposes of this review, the What is the prevalence of diabetes in tance compared with the condition that following terms are defined (adapted hospitals? prompted admission. Recent studies (1,2) from the American Diabetes Association The prevalence of diabetes in hospitalized have focused attention to the possibility [ADA] Expert Committee on the Diagno- adult patients is not known. In the year that hyperglycemia in the hospital is not sis and Classification of Diabetes Mellitus) 2000, 12.4% of hospital discharges in the necessarily a benign condition and that (3): U.S. listed diabetes as a diagnosis. The aggressive treatment of diabetes and hy- average length of stay was 5.4 days (4). perglycemia results in reduced mortality ● Medical history of diabetes: diabetes Diabetes was the principal diagnosis in and morbidity. The purpose of this tech- has been previously diagnosed and ac- only 8% of these hospitalizations. The ac- nical review is to evaluate the evidence knowledged by the patient’s treating curacy of using hospital discharge diag- relating to the management of hypergly- physician. nosis codes for identifying patients with ●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●● previously diagnosed diabetes has been From the 1Georgetown University Hospital, Washington, DC; the 2University of North Carolina, Chapel Hill, questioned. Discharge diagnosis codes North Carolina; 3Medstar Research Institute at Washington Hospital Center, Washington, DC; the 4Oregon may underestimate the true prevalence of 5 Health and Science University, Portland, Oregon; the VA Medical Center, Bay Pines, Florida; and the diabetes in hospitalized patients by as 6University of Washington, Seattle, Washington. Address correspondence and reprint requests to Dr. Stephen Clement, MD, Georgetown University much as 40% (5,6). In addition to having Hospital, Department of Endocrinology, Bldg. D, Rm. 232, 4000 Reservoir Rd., NW, Washington, DC a medical history of diabetes, patients pre- 20007. E-mail: [email protected].. senting to hospitals may have unrecog- Received and accepted for publication 1 August 2003. nized diabetes or hospital-related S.C. has received honoraria from Aventis and Pfizer. S.S.B. has received honoraria from Aventis and research support from BMS. M.F.M. has been on advisory panels for Aventis; has received honoraria from hyperglycemia. Umpierrez et al. (1) re- Aventis, Pfizer, Bristol Myers Squibb, Takeda, and Lilly; and has received grant support from Aventis, Pfizer, ported a 26% prevalence of known diabe- Lilly, Takeda, Novo Nordisk, Bayer, GlaxoSmithKline, and Hewlett Packard. A.A. has received honoraria tes in hospitalized patients in a from Aventis, Bayer, BMS, GlaxoSmithKline, Johnson & Johnson, Lilly, Novo Nordisk, Pfizer, and Takeda community teaching hospital. An addi- and research support from Aventis, BMS, GlaxoSmithKline, Johnson & Johnson, Lilly, Novo Nordisk, Pfizer, tional 12% of patients had unrecognized Roche, and Takeda. E.P.S. holds stock in Aventis. I.B.H. has received consulting fees from Eli Lilly, Aventis, Novo Nordisk, and Becton Dickinson and grant support from Novo Nordisk. diabetes or hospital-related hyperglyce- Additional information for this article can be found in two online appendixes at http:// mia as defined above. Levetan et al. (6) care.diabetesjournals.org. reported a 13% prevalence of laboratory- Abbreviations: ADA, American Diabetes Association; AMI, acute myocardial infarction; CDE, certified documented hyperglycemia (blood glu- diabetes educator; CHF, congestive heart failure; CK, creatinine kinase; CQI, continuous quality improve- Ͼ ment; CRP, C-reactive protein; CSII, continuous subcutaneous insulin infusion; CVD, cardiovascular dis- cose 200 mg/dl (11.1 mmol) in 1,034 ease; DIGAMI, Diabetes and Insulin-Glucose Infusion in Acute Myocardial Infarction; DSME, diabetes consecutively hospitalized adult patients. self-management education; DSWI, deep sternal wound infection; FFA, free fatty acid; GIK, glucose-insulin- Based on hospital chart review, 64% of potassium; ICAM, intercellular adhesion molecule; ICU, intensive care unit; IL, interleukin; IIT, intensive patients with hyperglycemia had preex- insulin therapy; JCAHO, Joint Commission of Accredited Hospital Organization; LIMP, lysosomal integral isting diabetes or were recognized as hav- membrane protein; MCP, monocyte chemoattractant protein; MI, myocardial infarction; MRI, magnetic resonance imaging; MRS, magnetic resonance spectroscopy; NF, nuclear factor; NPO, nothing by mouth; ing new-onset diabetes during PAI, plasminogen activator inhibitor; PCU, patient care unit; PKC, protein kinase C; PBMC, peripheral blood hospitalization. Thirty-six percent of the mononuclear cell; PMN, polymorphonuclear leukocyte; ROS, reactive oxygen species; TNF, tumor necrosis hyperglycemic patients remained unrec- factor; TPN, total parenteral nutrition; UKPDS, U.K. Prospective Diabetes Study. ognized as having diabetes in the dis- A table elsewhere in this issue shows conventional and Syste`me International (SI) units and conversion factors for many substances. charge summary, although diabetes or © 2004 by the American Diabetes Association. “hyperglycemia” was documented in DIABETES CARE, VOLUME 27, NUMBER 2, FEBRUARY 2004 553 Management of diabetes and hyperglycemia in hospitals the progress notes for one-third of these (10,11). From a mechanistic point of superoxide production in isolated human patients. view, the primary problem has been iden- neutrophils (31). Sato and colleagues Norhammar et al. (7) studied 181 tified as phagocyte dysfunction. Studies (32–34) used chemiluminescence to eval- consecutive patients admitted to the cor- have reported diverse defects in neutro- uate neutrophil bactericidal function. The onary care units of two hospitals in Swe- phil and monocyte function, including authors confirmed a relationship between den with acute myocardial infarction adherence, chemotaxis, phagocytosis, hyperglycemia and reduced superoxide (AMI), no diagnosis of diabetes, and a bacterial killing, and respiratory burst formation in neutrophils. This defect was blood glucose Ͻ200 mg/dl (Ͻ11.1 (10–20). Bagdade et al. (14) were among improved after treatment with an aldose mmol/l) on admission. A standard 75-g the first to attach a glucose value to im- reductase inhibitor. This finding suggests glucose tolerance test was done at dis- provement in granulocyte function when that increased activity of the aldose reduc- charge and again 3 months later. The au- they demonstrated significant improve- tase pathway makes a significant contri- thors found a 31% prevalence of diabetes ment in granulocyte adherence as the bution to the incidence of diabetes- at the time of hospital discharge and a mean fasting blood glucose was reduced related bacterial infections. 25% prevalence of diabetes 3 months af- from 293 Ϯ 20 to 198 Ϯ 29 mg/dl Laboratory evidence of the effect of ter discharge in this group with no previ- (16.3–11 mmol/l) in 10 poorly controlled hyperglycemia on the immune system ous diagnosis of diabetes. patients with diabetes. Other investiga- goes beyond the granulocyte. Nonenzy- Using the A1C test may be a valuable tors have demonstrated similar improve- matic glycation of immunoglobulins has case-finding tool for identifying diabetes ments in leukocyte function with been reported (35). Normal individuals in hospitalized patients. Greci et al. (8) treatment of hyperglycemia (17,21–23). exposed to transient glucose elevation reported that an A1C Ͼ6% was 100% In vitro trials attempting to define hyper- show rapid reduction in lymphocytes, in- specific and 57% sensitive for identifying glycemic thresholds found only rough es- cluding all lymphocyte subsets (36). In persons with diabetes in a small cohort of timates that a mean glucose Ͼ200 mg/dl patients with diabetes, hyperglycemia is patients admitted through the emergency (11.1 mmol/l) causes leukocyte dysfunc- similarly associated with reduced T-cell department of one hospital with a random tion (13,14,16,24–26). populations for both CD-4 and CD-8 sub- blood glucose Ն126
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