In Brief Multiple staff members and departments have a responsibility for various From R esearch to Practice / I n p aspects of nutrition therapy for glycemic management in the hospital setting. Implementation is initiated by physicians, nurse practitioners, and physician’s assistants and planned and operationalized by registered dietitians. Meals are delivered by food service staff, and nurses monitor and integrate glycemic control components into patients’ medical treatment plan. Although nutrition therapy is recognized as an important aspect of care in the hospital setting, it can also be challenging to appropriately coordinate meals with blood glucose monitoring and insulin administration. This article addresses current meal- time practices and recommendations to improve these processes in acute care.

The Mealtime Challenge: Nutrition and Glycemic Control in the Hospital atient Glycemic M ana g ement

Management of diabetes and hyper- (RDs) regarding current hospital meal glycemia has become an important service practices are also included. Donna B. Ryan, MPH, RN, RD, quality care indicator in the hospital setting. Multiple health care organi- Nutrition Therapy in the Hospital CDE, and Carrie S. Swift, MS, RD, MNT is a well-recognized component zations offer guidelines for glycemic BC-ADM, CDE of diabetes management, and experts control, including recommendations agree that it should be integrated into for medical nutrition therapy (MNT) the glycemic management of hospi- and consistent-carbohydrate meal talized patients.1,2,4 MNT is the legal plans.1–4 Additionally, the appropriate definition of nutrition counseling pro- timing of nutrition delivery, point-of- vided by an RD.7 The term applies care (POC) blood glucose monitoring, to the nutrition care process, which

and insulin therapy in the hospital is includes assessment of nutrition status; I recognized as a crucial step in the safe provision of nutrition interventions and effective care of patients.3,5 such as diet modification, counsel- Although these goals are essential ing, or specialized nutrition therapy; 8 to reducing harm and improving out- and monitoring and evaluation. RDs knowledgeable in glycemic manage- comes, how to achieve them can be ment are the preferred health care a challenge for hospitals. A quality team members to provide diabetes improvement approach with strong MNT.7 Because of limited hospital administrative support and a multidis- staffing of clinical dietitians, MNT ciplinary steering committee is needed provided by an RD is generally only to improve the quality of patient available by consultation or to patients care.2,3,6 identified to be at high nutritional This article summarizes nutrition risk. The broader term “nutrition therapy goals and recommendations therapy” will be used in this article for glycemic control in noncritically to include other aspects of nutrition ill, hospitalized patients; reviews the care provided by various health care rationale for consistent-carbohy- professionals during hospitalizations. drate meal plans and liberalizing the Glycemic control is the primary nutrition goal for hospitalized patients “diabetic diet;” and describes suc- with diabetes. Additional nutrition cessful mealtime practices to improve therapy goals include promoting opti- coordination of meal delivery with mal caloric and nutrient intake to meet blood glucose monitoring and insu- metabolic needs; aiding in recovery lin administration. Results from an from illness, surgery, and disease; and informal survey of inpatient diabetes allowing for food preferences related educators and registered dietitians to patients’ personal, cultural, ethnic, Diabetes Spectrum Volume 27, Number 3, 2014 163 Table 1. Key Nutrition Recommendations for Diabetes and Glycemic Control in the Hospital Topic Details Nutrition therapy Implementation of nutrition therapy improves the care of patients with diabetes and hyperglycemia during hospitalization. RDs who are knowledgeable about glycemic control are the preferred team members to provide MNT.1–4 Consistent-carbohydrate meal plan The consistent-carbohydrate meal plan is the established standard for hospitalized patients with diabetes and is useful to improve the accuracy of mealtime insulin administration.1,4 • Evidence does not support the use of “no concentrated sweets” or “no sugar” diets. Sucrose-containing foods may be incorporated into a consistent-carbohydrate meal plan.7 • The “ADA diet” is not current practice and should not be used. It may unnecessarily restrict calories and patients’ preferred foods. Since 1994, ADA has not recommended a specific type of diet or macronutrient distribution.9 Liberalized diets Inadequate nutrition intake is common in hospitalized patients. To improve oral intake and enhance patients’ satisfaction, liberalized diets without caloric restriction (e.g., a general diet with consistent amounts of carbohydrate), room service on demand, and increased availability of foods that meet personal, cultural, or religious food preferences have been implemented in some acute-care facilities.9 Coordination of meal delivery Diabetes educators and RDs are key interdisciplinary team members to improve coordination of meal delivery, insulin administration, and POC blood glucose monitoring to optimize glycemic control.10

and religious beliefs. Additionally, an of carbohydrate offered should be lead to increased glycemic variability. individualized discharge plan should from whole grains, fruit, legumes, With appropriate training, nursing be developed for self-management vegetables, and low-fat dairy foods, assistants and meal service represen- training and follow-up.1,3,4 Key rec- when possible. tatives can play a role in increasing ommendations for meal planning to Sucrose-containing foods can the accuracy of carbohydrate estima- meet patients’ nutrient requirements be offered on this meal plan, and tion. Bedside tray delivery provides and improve glycemic control in the including them may help an indi- opportunities for communication with hospital setting have been identified vidual meet caloric intake goals and patients and family members about the (Table 1).1– 4,7,9,10 provide for individual food prefer- carbohydrate content of menu items or ences.11 Misunderstanding of the snacks.9 With appropriate insulin dos- Consistent-Carbohydrate Meal inclusion of sucrose-containing foods ing and administration, snacks do not Planning remains common. Some patients, pro- have to be automatically included in Because of the limited available evi- viders, and hospital staff may think the nutrition plan for patients on basal dence identifying ideal meal plans that patients are not on a “diabetic insulin therapy. Inclusion of snacks for hospitalized patients, expert con- diet” unless sucrose is restricted. should be based on patients’ prefer- sensus has been the basis for current Additionally, patients and families ences and nutrition goals.12 recommendations. Because carbo- may lack understanding of the meal Guidelines should be in place to hydrate intake provides the primary plan, potentially leading to excesses address the involvement of patients nutritional effect on blood glucose, in calorie and carbohydrate intake and their family members in self-care consistent-carbohydrate meal plan- from foods brought in from outside tasks such as blood glucose monitor- ning has evolved as the accepted the facility or further restriction when ing, reporting carbohydrate intake standard for glycemic control. These well-meaning family members remove to staff members, and appropriately meal plans offer a practical method of food from the meal tray. notifying staff members about food serving food to patients, while poten- brought in from outside the hospi- tially improving glycemia. Specific Strategies for success with consistent- tal. Nurses and nursing assistants calorie levels are not recommended; carbohydrate meal planning can help to educate patients and rather, a consistent amount of carbo- A key teaching point for hospital staff their families by taking advantage hydrate is offered at meals and snacks is that the amount of carbohydrate of teachable moments during patient from day to day. For convenience of eaten, rather than the sugar content care. Resources for carbohydrate esti- implementation, many facilities pro- or the percentage of the meal eaten, mation should be readily available to vide consistent-carbohydrate meal has the greatest impact on blood glu- staff and patients. Having the carbo- plans with specific calorie levels that cose. If the only parameter monitored hydrate content of foods noted on the may not address the actual caloric at the facility is the percentage of the menu assists patients with selecting the needs of a given patient. To meet meal eaten, over- or underestimation appropriate foods and can be used by nutrient requirements, the majority of total carbohydrate consumed might nursing staff as a teaching tool to help 164 Diabetes Spectrum Volume 27, Number 3, 2014 patients better understand the con- metabolic control, and promote posi- to patients with diabetes, which has cept of carbohydrate counting. When tive health status. To meet therapeutic created additional challenges in coor- From R esearch to Practice / I n p patients gain a better understanding requirements, these diets may be more dination of meals with insulin therapy of which foods contain carbohydrate, restrictive than necessary, especially and blood glucose monitoring.23,24 appropriate substitutions can be made for older, malnourished, and acutely Nurses are essential to the process; more easily to meet individual pref- ill patients who are self-limiting their however, they may not be supported erences. Including the carbohydrate food intake. Diets that are overly by optimal procedures or fully under- content of foods on the general diet restrictive may unintentionally lead stand the effect that appropriate meal menu, not solely on a diabetes-specific to decreased food intake, weight and medication timing can have on menu, allows for a wider variety of loss, and under-nutrition, which is metabolic control.23 food substitutions. Patients’ glycemic the opposite of the desired effect. goals are more likely to be achieved Allowing patients to eat a more lib- Strategies for Improving Mealtime when patients, nurses, and meal ser- eralized meal plan may help improve Processes vice staff understand carbohydrate their nutrition status. Providing the best patient care counting and the rationale behind the Patients who are not eating well requires an organizational culture of meal plan.9 should be identified and referred for inter-professional teamwork and com- consultation with an RD for nutri- munication. Processes that promote Nutrition Status in Acute Care tion assessment and intervention. standardization and reliability, which Barriers to adequate nutrition intake Patients who are not able to meet support nurses in providing timely in the hospital setting are many and their nutrition needs on the ordered care, may aid in patient outcome include altered appetite, medical con- improvement.25,26 Several hospitals diet may benefit from nutrition sup- atient Glycemic M ana g ement ditions causing difficulty or inability plements or nutrition support such have reported success with quality to eat, NPO (nothing by mouth) as enteral nutrition. A variety of dis- improvement initiatives to improve status, nausea and vomiting, gas- ease-specific enteral formulas for the coordination of timing of meals, trointestinal complaints, increased glycemic control are available and blood glucose monitoring, and insu- nutrition needs because of illness typically have lower carbohydrate lin delivery. and catabolic stress, foods different and higher monounsaturated fat As part of an initiative aimed from home, unfamiliar meal patterns, levels than standard formulas.4 The at reducing hypoglycemia, one restrictive or inappropriate diet orders, variable effects of enteral nutrition acute care hospital implemented a missed or delayed meals because of on postprandial glucose and patient multidisciplinary approach.27 The scheduled procedures, hospital meal- outcomes have been reported in the scheduled times for mealtime insu- time processes, and failure to meet literature and are beyond the scope lin were changed on the medication patients’ personal or cultural food of this article.19–22 Further research administration record to coincide preferences.4,12–14 With all of these is needed to recommend the use of with meal service, with a message potential barriers, it is not surprising diabetes-specific enteral formulas for to “administer within 10 minutes of that malnutrition is common in acute hospitalized patients with hyperglyce- meal.” Additionally, the pharmacy care. A recent observational study14 mia.21 Regardless of the type of enteral department provided the food service found that 44–59% of hospitalized supplement provided, the importance department with a list of patients tak- I patients with type 1 or type 2 diabe- of timely glucose monitoring, proac- ing mealtime insulin. Food service tes and receiving subcutaneous insulin tive insulin adjustment, and frequent staff flagged trays for patients receiv- (n = 434) ate < 50% of offered meals. reassessment of patient status is cru- ing insulin, called the units when Eighteen to 34% of patients ate no cial to preventing iatrogenic hypo- and meals were leaving the kitchen, and food at all. Only 12–25% ate all of hyperglycemia and to maintaining notified nurses when meals arrived on the food offered. These findings are adequate glycemic control. the unit and also when a tray remained consistent with literature regarding on the cart because a patient was not hospital plate waste and malnutri- Challenges of Coordinating Meal in the room at delivery time. Blood tion.15–17 Poor oral intake also may Delivery, Glucose Monitoring, and glucose monitoring was completed contribute to hypoglycemia when Insulin Administration after the first notification of trays leav- mealtime insulin dosing is not adjusted There is an increasing awareness ing the kitchen. Nurses were then able appropriately. For patients who have a of hospital patients as customers. to administer mealtime insulin with poor appetite, administering mealtime Hospitals have a strong focus on cus- tray delivery.27 The mealtime improve- insulin immediately after meals may tomer service with the advent of public ment process contributed to the overall allow for better matching of insulin reporting of patient satisfaction scores. system goal of reducing hypoglycemia. to carbohydrate actually consumed, As a result, many facilities have transi- Another academic teaching hospi- decreasing the risk for hypoglycemia. tioned to meal delivery services such as tal utilized a time-in-motion study and During hospitalization, insulin doses room service, through which patients discovered that staff members were may vary significantly from patients’ have flexibility in ordering meals and testing blood glucose ranging from usual insulin regimen not only because choosing the time they would like to 166 minutes before to 98 minutes of changes in patients’ normal eating eat. Room service, or “on demand” after meals.28 The hospital adopted routine, but also because of medica- meal service, may increase patient interventions to standardize clinical tions, the stress of illness, surgery, or satisfaction and provide cost savings processes, including meal delivery other procedures.12,18 while improving food quality.13 Many time, and implemented a nurse-driven Therapeutic diets are intended hospitals have implemented this type process to coordinate glucose moni- to help treat disease states, improve of meal service and made it available toring, meal delivery, and insulin Diabetes Spectrum Volume 27, Number 3, 2014 165 administration. The time difference and adherence to hospital standards of food texture from clear liquid to between blood glucose monitoring care. Coordination and communica- regular meals) and bedside meal delivery decreased tion among health professionals across • Encourage patient participation in from an average of 44 minutes to an disciplines is a shared responsibility to insulin administration and man- average of 14 minutes. Patients receiv- avoid the “silo effect,” which occurs agement where appropriate ing insulin within 30 minutes of blood when hospital departments do not glucose monitoring increased from 39 communicate with and make decisions Trends in Meal Service in to 97%. independent of each other.26 Ongoing Acute Care A study at an academic medical collaboration between hospital nutri- An informal survey was developed center29 examining the time between tion services, nursing leadership, by the authors (D. Ryan, C. Swift, blood glucose monitoring, insulin pharmacists, and physician champi- unpublished observations) to provide administration, and the morning ons is vital to developing sustainable a snapshot of current hospital meal breakfast meal revealed that insu- and reproducible processes. Ideally, service practices. The survey ques- lin was given 93 ± 53 minutes after each facility should choose a preferred, tions focused on 1) how diets are blood glucose monitoring. Breakfast standardized approach based on its ordered, communicated, and deliv- was provided 73 ± 37 minutes after unique needs.4 ered and 2) what processes are in place insulin delivery. Eighty percent of Several organizations and authors for coordinating meal delivery with patients whose breakfast was deliv- have recommended quality improve- POC blood glucose monitoring and ered > 45 minutes after insulin had ment interventions to address insulin administration. One hundred prelunch glucose values > 180 mg/dl. mealtime processes.2,18,31–35 These surveys were completed. A link to the survey “Meal Service for Inpatients A significant reduction was seen when strategic approaches include: with Diabetes (Non-Critical Care)” patients received insulin < 45 minutes • Reduce the time between blood was posted in January 2014 on the before breakfast, with 43% experi- glucose monitoring, insulin admin- online communities of the Diabetes encing prelunch blood glucose levels istration, and meals; consider a Care and Education dietetic practice > 180 mg/dl. goal of 30 minutes < group of the Academy of Nutrition A recent pilot program at a uni- • Adapt practice to recheck blood 30 and Dietetics and the inpatient man- versity-affiliated hospital informed glucose if a meal is not delivered nurses of the exact time of meal tray agement community of interest of the within 30 minutes of the first glu- American Association of Diabetes delivery to patients and reduced the cose check period between insulin dosing and Educators and distributed via email to • Provide the food service depart- meal consumption by half. To accom- clinical nutrition managers of Touch ment with a list of patients taking plish this, meal service staff handed Point Support Services, a hospital mealtime insulin so tray delivery a card to unit secretaries identify- food service provider. Members of can be communicated to nurses ing patients with diabetes who had these groups include, among others, • Reduce the number of staff received their meal. The secretaries dietitians, nurses, diabetes educators, then notified the nurses. Improvement involved in POC glucose monitor- and clinical pharmacists who actively was seen in on-time mealtime insu- ing, insulin administration, and participate in online professional lin administration, and glycemic meal tray delivery (e.g., have nurses networks focused on diabetes care. control improved with no increase who are responsible for insulin Limits were not set on the number of in hypoglycemia. administration also perform the participants per facility, so there may To ensure accurate mealtime insu- blood glucose monitoring or have have been multiple respondents from lin dosing, it is important to include nursing assistants who are respon- a single facility. Questions included communication with patients and sible for glucose monitoring also multiple choice, multiple answer, and families, meal service representatives, deliver meal trays) open text formats. and nursing staff. In addition, ongo- • Provide safeguards to prevent Half of the respondents indicated ing education for staff, patients, and patients from being deprived of that they worked in a community family members to increase under- food and nutrition after receiving hospital. Other settings included standing of the facility’s meal system mealtime insulin (e.g., when they academic/teaching hospitals (21%), is recommended to improve coordina- are sent for dialysis, medical pro- urban settings (13%), and rural tion of these glycemic management cedures, or testing at the normal settings (21%). components. Because of their special- mealtime) Nearly all (88%) of the respondents ized knowledge and skills, RDs and • Stock appropriate snacks on the reported that consistent-carbohydrate inpatient diabetes educators are the unit for nurses to offer patients meal plans are offered at their facili- team members best suited to over- arriving between mealtimes or as ties and that carbohydrate content of see staff training and education to nighttime snacks as needed foods was included on patient menus improve the coordination of meal • Ensure that patients’ insulin regi- or meal tickets (90%). A surprising consumption, glucose monitoring, and men incorporates their prandial finding was the wide variation in insulin administration. carbohydrate intake carbohydrate calculations for insulin Understanding hospital-specific • Modify insulin order sets to dosing. Whereas 100% of respon- nursing and pharmacy policies for the address times when patients’ meals dents indicated that they count starchy definition and time frame of “a.c.” are interrupted foods, 38% also include nonstarchy (ante cibum, or premeal) orders for • Reassess insulin requirements after vegetables, 37% include condiments, medications and procedures may also any change in nutrition status or and 16% include protein (e.g., meat, be helpful to guide mealtime practices diet orders (e.g., progression in fish, and poultry). 166 Diabetes Spectrum Volume 27, Number 3, 2014 More than one-third (37%) not be automatically restricted solely References reported that room service is available, based on a “diabetic diet” order. 1American Diabetes Association: Standards of From R esearch to Practice / I n p and the most commonly identified There are too few inpatient clini- medical care in diabetes—2014. Diabetes Care 17 staff members to deliver meals were cal dietitians to assess the caloric (Suppl. 1):S514–S480, 2014 food service associates (84%). Forty- needs of all patients with diabetes. 2Umpierrez GE, Hellman R, Korytkowski MT, two percent of respondents indicated Kosiblorod M, Maynard GA, Montori VM, Seley Allowing nursing staff the autonomy JJ, van den Berghe G: Management of hypergly- that food service associates directly and resources to be able to offer food cemia in hospitalized patients in noncritical care notify nurses of meal delivery. Other substitutions and to recalculate meal- setting: an Endocrine Society clinic practice guide- nurse notification systems included time insulin dosing based on patients’ line. J Clin Endocrinol Metabol 97:16–38, 2012 nursing unit clerks (16%), mealtimes preferred foods may help patients meet 3Moghissi E, Korytkowski M, DiNardo M, Einhorn D, Hellman R, Hirsch I, Inzucchi S, Ismail-Beigi posted on the unit (25%), and visual their nutrition needs and improve F, Kirkman MS, Umpierrez G: AACE and ADA notification (“when they see the trays their satisfaction with meals. It is also consensus statement on inpatient glycemic control. are on the unit”) (34%). important for nursing staff to help Endocr Pract 15:1–17, 2009 Seventy-five percent indicated identify patients who need additional 4Boucher JL, Swift CS, Franz MJ, Kulkarni K, that there is no formal process to Schafer RG, Pritchett E, Clark NG: Inpatient nutrition assessment by an RD. management of diabetes and hyperglycemia: impli- identify when patients miss a meal. cations for nutrition practice and food and nutrition Respondents who did report a more Summary professionals. J Am Diet Assoc 107:105–111, 2007 formal system shared a variety of In the acute care setting, meal deliv- 5Wesorick D, O’Malley C, Rushakoff R, Larsen communication techniques, including ery and mealtime nursing activities K, Magee M: Management of diabetes and hyperglycemia in the hospital: a practical guide to writing on meal tickets, documenta- are interwoven and interdependent. subcutaneous insulin use in noncritically ill adult

tion in electronic and paper charts, Multiple staff members and depart- patients. J Hosp Med 3 (Suppl. 5):S17–S28, 2008 atient Glycemic M ana g ement having nurses collect the meal trays ments have responsibilities for various 6Maynard G, Umpierrez G: Introduction: overview of patients on carbohydrate-consistent aspects of nutrition therapy for gly- of efforts and lessons learned. J Hosp Med 3 (Suppl. diets, having food service and nursing cemic management in the hospital 5):S29–S41, 2008 assistant associates trained to evalu- setting. Implementation is initiated 7American Diabetes Association: Nutrition therapy recommendations for the management of adults ate carbohydrate percentages eaten, by physicians, nurse practitioners, with diabetes. Diabetes Care 37 (Suppl. 1):S120– and including family and patients or physician’s assistants and planned S143, 2014 to inform nurses about uncon- and operationalized by RDs. Meals 8Lacey K, Pritchett E: Nutrition care process and sumed foods. are delivered by food service staff model: ADA adopts road map to quality care Regarding diet orders, consistent- and outcomes management. J Am Diet Assoc members, and nurses monitor and 103:1061–1072, 2003 carbohydrate diets were identified integrate glycemic control compo- 9Swift CS: Nutrition therapy for the hospital- most often (53%) for patients with nents into patients’ medical treatment ized and long-term care patient with diabetes. In diabetes. Diet orders for “ADA diets” plan. Teamwork, communication, and American Diabetes Association Guide to Nutrition (37%), as well as “no concentrated administrative support are needed to Therapy for Diabetes. 2nd ed. Franz MJ, Evert AB, Eds. Alexandria, Va., American Diabetes sweets” (23%), persist in some facili- meet the challenge of providing safe Association, 2012, p. 229–245 ties. Some facilities indicated that and effective glycemic control in the 10American Association of Diabetes Educators: consistent-carbohydrate meals are hospital setting. Position statement: diabetes inpatient management. delivered regardless of the type of Additional research is needed to Diabetes Educ 38:142–146, 2012 I “diabetic diet” ordered. identify the best strategies for coordi- 11Evert AB, Boucher JL, Cypress M, Dunbar SA, nating these efforts toward improved Franz MJ, Mayer-Davis EJ, Neumiller JJ, Urbanski Diet Orders: An Area P, Yancy W: Nutrition therapy recommendations patient outcomes. Research is also for management of adults with diabetes. Diabetes of Opportunity needed to determine optimal meal- Care 37 (Suppl. 1):S120–S123, 2014 Although evidence suggests that some planning practices for hospitalized 12Swift CS, Boucher JL: Nutrition care for hospital- changes in meal service are taking patients with diabetes and hypergly- ized individuals with diabetes. Diabetes Spectrum place to improve inpatient glycemic cemia. Exploring available options to 18:34–38, 2005 management, many hospitals still seem implement consistent-carbohydrate 13McKnight KA, Carter L: From trays to tube to rely on efforts to make changes fit feeding: overcoming the challenges of hospital meal plans and offer more liberalized nutrition and glycemic control. Diabetes Spectrum into their existing clinical practices. diets is encouraged. 21:233–240, 2008 This is evident when it comes to diet 14Modic MB, Kozak A, Siedleci SL, Nowak D, orders and how they are carried out. Parella D, Morris MP, Braun L, Schwarm S, Binion In a 2002 editorial,36 Hirsch asked, Acknowledgments S: Do we know what our patients with diabetes The authors thank the members of are eating in the hospital? Diabetes Spectrum “Is it realistic to think we can success- 24:100–110, 2011 fully put the ‘1800-calorie ADA diet’ the American Association of Diabetes 15van Bokhorts-de van der Schueren MA, to rest forevermore?” Unfortunately, Educators’ inpatient management Roosemalen MM, Weijs PJ, Langius JA: High more than a decade after this editorial community of interest; members of the waste contributes to low food intake in hospitalized was published, this outdated diet order Academy of Nutrition and Dietetics patients. Nutr Clin Pract 27:274–280, 2012 is still entered and provided in many Diabetes Care and Education dietetic 16Tappenden KA, Quatrara B, Parkhurst ML, facilities. Other hospitals have imple- practice group; and the RDs and clin- Malone AM, Fanjiang G, Zeigler TR: Critical role of nutrition in improving quality of care: an mented consistent-carbohydrate meal ical nurse managers of Touch Point interdisciplinary call to action to address adult hos- plans with specific calorie levels that who responded to our survey. Thanks pital malnutrition. JPEN J Parenter Enteral Nutr are, in effect, “ADA diets” that have also go to Amy Musselman, MS, RD, 37:482–497, 2013 just been relabeled. The caloric needs Marc Kummer, MD, and Edith Baker, 17Dupertuis YM, Kossovsky MP, Kyle UG, Raguso CA, Genton L, Pichard C: Food intake in 1707 of hospitalized patients with diabetes RD, LDN, CDE, of Sacred Heart hospitalised patients: a prospective comprehensive vary significantly, so calories should Hospital in Pensacola, Fla. hospital survey. Clin Nutr 22:115–123, 2003 Diabetes Spectrum Volume 27, Number 3, 2014 167 18Society of Hospital Medicine Glycemic Control 25Rutherford P, Lee B, Greiner A: Transforming ReduceAdverseDrugEventsInvolvingInsulin.aspx. Task Force: Workbook for Improvement: Improving care at the bedside. IHI Innovation Series white Accessed 17 February 2014

Glycemic Control, Preventing Hypoglycemia, paper. Boston, Mass., Institute for Healthcare 33 and Optimizing Care of the Inpatient with Improvement, 2004. Available from http:// Meisel S: A high reliability approach to adverse Hyperglycemia and Diabetes. Available from www.ihi.org/resources/Pages/IHIWhitePapers/ drug events. Available from http://www.hret-hen. http://www.hospitalmedicine.org/Web/ TransformingCareattheBedsideWhitePaper.aspx. org/index.php?option=com_phocadownload&view Quality_Innovation/Implementation_Toolkits/ Accessed 9 June 2014 =category&id=232:adverse-drug-events. Accessed Glycemic_Control/Web/Quality___Innovation/ 9 June 2014 26Weller J, Boyd, M, Cumin D: Teams, tribes and Implementation_Toolkit/Glycemic/Best_Practices/ 34 patient safety: overcoming barriers to effec- Moghissi E: Addressing hyperglycemia from hos- Managing_Diabetes.aspx. Accessed 10 June 2014 tive teamwork in healthcare. Postgrad Med J pital admission to discharge. Curr Med Res Opin 19Hise ME, Fuhrman MP: The effect of diabetes- 90:149–154, 2014 26:589–598, 2010 specific enteral formulae on clinical and glycemic 27Eady C: Reducing hypoglycemia [PowerPoint 35Institute of Safe Medication Practice: Acute care indicators. Pract Gastroenterol May 2009. presentation]. Available from http://www.hret-hen. guidelines for timely administration of scheduled Available from http://www.medicine.virginia.edu/ org/index.php?option=com_phocadownload&view medications, 2011. Available from http://www. clinical/departments/medicine/divisions/digestive- =category&id=232:adverse-drug-events. Accessed ismp.org/tools/guidelines/acutecare/tasm.pdf. health/nutrition-support-team/nutrition-articles/ 9 June 2014 Accessed 17 February 2014 HiseArticle.pdf. Accessed 9 June 2014 28Matonti R, Rogers K, Hoeppner S: Quality of 36Hirsch I: The death of the “1800-calorie ADA 20 Vindedzia SA, Sherriff JL, Stanton KG: care initiative: blood glucose timing, food delivery diet.” Clinical Diabetes 20:51–52, 2002 Hypoglycemia in insulin-treated adults on estab- and insulin administration [Abstract]. Available lished nasogastric feeding in the general ward: a from http://dst.sagepub.com/content/5/2/456.full. systematic review. Diabetes Educ 40:290–298, pdf+html. Accessed 9 June 2014 2014 Donna B. Ryan, MPH, RN, RD, 29Cohen LS, Sedhom L, Salifu M, Friedman EA: 21 CDE, is a certified diabetes educa- McMahon MM, Nystrom E, Braunschweig Inpatient diabetes management: examining morn- C, Miles J, Compher C; American Society for ing practice in an acute care setting. Diabetes Educ tor and patient education manager Parental and Enteral Nutrition (A.S.P.E.N.) Board 33:483–492, 2007 of the diabetes education, smoking of Directors; American Society for Parenteral and Enteral Nutrition: A.S.P.E.N. clinical guidelines: 30Mallikarjuna S, Aziz S, Nallala D, Asghar R, cessation, and asthma education nutrition support of adult patients with hypergly- Burns C, Jakoby M: A pilot program to coordinate programs at Sacred Heart Hospital cemia. JPEN J Parenter Enteral Nutr 37:23–36, food delivery and mealtime insulin administration 2013. in the hospital improves on time insulin dosing and in Pensacola, Fla. Carrie S. Swift, glycemic control [Abstract]. Available from https:// MS, RD, BC-ADM, CDE, is a certi- 22Gosmanov AR, Umpierrez GE: Management of www.aace.com/files/abstracts-2013.pdf . Accessed hyperglycemia during enteral and parenteral nutri- 9 June 2014 fied diabetes educator and registered tion therapy. Curr Diabetes Rep 13:155–162, 2013 31Milligan PE, Heard KM, Hall EM, Krettek J: dietitian at the Kadlec Medical 23Houck PM, Tirumalasetty NN, Meadows Using automation to detect severe hypoglycemia, Center Diabetes Learning Center in RY: Insulin administration and meal delivery collect causative factors and inform preven- Richland, Wash. coordination for hospitalized patients. Oschner J tion strategies across a large health care system. 13:327–333, 2013 Available from http://www.ashpfoundation.org/ © 2014 by the American Diabetes Association. BJCHealthcareInitiative. Accessed 17 February 24Dungan KM, Sagrilla C, Mahmoud A, Kwame Readers may use this article as long as the work 2014 O: Prandial insulin dosing using the carbohydrate is properly cited, the use is educational and not counting technique in hospitalized patients with 32Institute for Healthcare Improvement: Reduce for profit, and the work is not altered. See http:// type 2 diabetes. Diabetes Care 30:3476–3482, adverse drug events involving insulin. Available creativecommons.org/licenses/by-nc-nd/3.0 2013 from http://www.ihi.org/resources/Pages/Changes/ for details.

168 Diabetes Spectrum Volume 27, Number 3, 2014