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Diabetes
Unrecognized diabetes is often discovered
when patients are admitted for
a physiologic stressor such as infection
or myocardial infarction. Hyperglycemia
related to diabetes is usually identified
when the first complete metabolic panel
reveals a fasting blood glucose ≥ 126 mg/
dL, a random blood glucose ≥ 200 mg/
dL, or a hemoglobin A 1c ≥ 6.5%. 3
Hyperglycemia related to hospitalization
may include stress hyperglycemia
Unrecognized diabetes
is often discovered
when patients are
admitted for treatment
of a physiologic stressor
such as infection or
heart attack.
Hyperglycemia is usually
identified in a complete
metabolic panel.
resulting from surgical procedures or use
of other medications such as steroids. 4 In
stress hyperglycemia, a patient meets the
criteria for hyperglycemia with a random
blood sugar ≥ 140 mg/dL, but he or she
does not meet the hemoglobin A 1c criteria
of > 6.5%. These patients have blood
sugars that often return to normal after
the stress is removed, but they should
be monitored closely for development of
prediabetes or diabetes after discharge. 4
Diagnostic Criteria
Diagnose DKA when the blood glucose is
≥ 250 mg/dL, arterial pH is ≤ 7.30, serum
bicarbonate is < 15 mEq/L, and positive
serum ketones are present. 5 Diagnose
HHS when blood glucose is 600 mg/dL or
greater, serum osmolarity is 320 mOsm/
kg or greater, profound dehydration is
present with elevated serum blood urea
nitrogen > 30 mg/dL, small ketonuria are
present, and bicarbonate > 15 mEq/L. 6
Table 2
Sliding Scale Insulin Protocol
Reevaluate insulin orders if on protocol more than 24 to 48 hrs
Nursing Orders
Assessments
__ Metered blood glucose before meals and at 2100, if able to take nutrition orally
__ Metered blood glucose every 6 hours if patient is not eating by mouth, on total
parenteral nutrition or continuous feedings
__ Metered blood glucose at 0300
__ Metered blood glucose before meals
__ Metered blood glucose at bedtime
__ Metered blood glucose (specify): ____________
Contingency
__ Notify physician if metered blood glucose is less than 70 mg/dL.
__ Notify physician if metered blood glucose is greater than 180 mg/dL for 2 consecutive
checks.
__ Notify physician of any metered blood glucose greater than 300 mg/dL.
Interventions
__ Discontinue all previous sliding scale insulin orders.
__ Discontinue all current insulin infusion orders.
__ If patient is unable to take food by mouth at any time, hold regular/aspart insulin.
__ Administer insulin before meals only for patients taking oral nutrition. (No bedtime
dose given unless provider orders.)
__ Administer insulin every 6 hours for patients who are not eating by mouth, on total
parenteral nutrition or continuous feedings.
__ Aspart insulin should be given when food tray is available.
Laboratory
__ Hemoglobin A 1c (GLYH) if not performed within the last 60 days.
Medications
Insulin
• Avoid sliding scale use in poorly controlled type 2 diabetes patients and in all type 1
diabetes patients. If patient not controlled, consider using insulin infusion orders.
• If patient continues to require correctional insulin, consider starting basal–bolus insulin
protocol.
__ NO insulin for metered blood glucose less than 150 mg/dL
__ Notify provider and provide NO insulin if metered blood glucose is greater than 400 mg/dL.
Provider Orders
Aspart (Novolog) Insulin Regular Insulin
- If metered blood glucose 150 mg/dL–200 mg/dL, give 2 units or (specify): ________units
- If metered blood glucose 201 mg/dL–250 mg/dL, give 4 units or (specify): ________units
- If metered blood glucose 251 mg/dL–300 mg/dL, give 6 units or (specify): ________units
- If metered blood glucose 301 mg/dL–350 mg/dL, give 8 units or (specify): ________units
- If metered blood glucose 351 mg/dL–400 mg/dL, give 10 units or (specify): ________units
Provider Signature/ID No: _____________________________________________
Date/Time: __________________
Diagnostic Tests
Order hemoglobin A 1c testing on all
patients with a known diagnosis of diabetes
if a previous value collected within
the prior 2 to 3 months is not available. 4
Also order this test for any patient with
a blood glucose level > 140 mg/dL.
Values > 6.5% suggest that the patient
had diabetes before admission. 1 Blood
glucose targets on noncritical care units
are premeal < 140 mg/dL and random
blood glucose < 180 mg/dL. 4
Clinical Management
In the hospital setting, insulin therapy is
the preferred method of glycemic control
for patients with diabetes. No data
about the safety and efficacy of inpatient
administration of oral agents have been
published.
Oral medications have a limited role
in the management of hyperglycemia
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