Standards of Care in Diabetes - 2024

Diabetes Care Volume 47, Supplement 1, January 2024 S295
16. Diabetes Care in the Hospital: American Diabetes Association

Professional Practice Committee*
Standards of Care in Diabetes—
2024
Diabetes Care 2024;47(Suppl. 1):S295–S306 | https://doi.org/10.2337/dc24-S016
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16. DIABETES CARE IN THE HOSPITAL
The American Diabetes Association (ADA) “Standards of Care in Diabetes” includes
the ADA’s current clinical practice recommendations and is intended to provide the
components of diabetes care, general treatment goals and guidelines, and tools to
evaluate quality of care. Members of the ADA Professional Practice Committee, an
interprofessional expert committee, are responsible for updating the Standards of
Care annually, or more frequently as warranted. For a detailed description of
ADA standards, statements, and reports, as well as the evidence-grading system
for ADA’s clinical practice recommendations and a full list of Professional Prac-
tice Committee members, please refer to Introduction and Methodology. Read-
ers who wish to comment on the Standards of Care are invited to do so at
professional.diabetes.org/SOC.
Among hospitalized individuals, hyperglycemia, hypoglycemia, and glucose variability

are associated with adverse outcomes, including increased morbidity and mortality
(1). Identification and careful management of people with diabetes and dysglycemia
during hospitalization has direct and immediate benefits. Diabetes management in
the inpatient setting is facilitated by identification and treatment of hyperglycemia
prior to elective procedures, a dedicated inpatient diabetes management service ap-
plying validated standards of care, and a proactive transition plan for outpatient dia-
betes care with timely prearranged follow-up appointments. These steps can
improve outcomes, shorten hospital stays, and reduce the need for readmission and
emergency department visits. For older hospitalized individuals or for people with di-
abetes in long-term care facilities, please see Section 13, “Older Adults.”
HOSPITAL CARE DELIVERY STANDARDS
Recommendations
16.1 Perform an A1C test on all people with diabetes or hyperglycemia (random
blood glucose >140 mg/dL [>7.8 mmol/L]) admitted to the hospital if no A1C test *A complete list of members of the American
result is available from the prior 3 months. B Diabetes Association Professional Practice Committee
can be found at https://doi.org/10.2337/dc24-SINT.
16.2 Institutions should implement protocols using validated written or comput-
erized provider order entry sets for management of dysglycemia in the hospital Duality of interest information for each author is
available at https://doi.org/10.2337/dc24-SDIS.
(including emergency department, intensive care unit [ICU] and non-ICU wards,
gynecology-obstetrics/delivery units, dialysis suites, and behavioral health units) Suggested citation: American Diabetes Association
Professional Practice Committee. 16. Diabetes care
that allow for a personalized approach, including glucose monitoring, insulin and/ in the hospital: Standards of Care in Diabetes—
or noninsulin therapy, hypoglycemia management, diabetes self-management educa- 2024. Diabetes Care 2024;47(Suppl. 1):S295–S306
tion, nutrition recommendations, and transitions of care. B © 2023 by the American Diabetes Association.
Readers may use this article as long as the
work is properly cited, the use is educational
Considerations on Admission and not for profit, and the work is not altered.
High-quality hospital care for diabetes requires standards for care delivery, which are More information is available at https://www
best implemented using structured order sets and quality improvement strategies for .diabetesjournals.org/journals/pages/license.
S296 Diabetes Care in the Hospital Diabetes Care Volume 47, Supplement 1, January 2024
process improvement. Unfortunately, “best Diabetes Care Specialists in the

critically ill individuals and are accept-
practice” protocols, reviews, and guidelines Hospital
able if they can be achieved without
are inconsistently implemented within hos- Recommendation significant hypoglycemia. B
pitals (2). To correct this, medical centers 16.3 When caring for hospitalized peo-
striving for optimal inpatient diabetes ple with diabetes (with an existing or
treatment should establish protocols and new diagnosis) or stress hyperglycemia, Standard Definitions of Glucose
structured order sets, which include com- consult with a specialized diabetes or Abnormalities
puterized provider order entry (CPOE). glucose management team when ac- Hyperglycemia in hospitalized individuals is
Institutions are encouraged to perform cessible. B defined as blood glucose levels >140 mg/dL
audits regularly to monitor proper use and (>7.8 mmol/L) (2). An admission A1C value
institute educational/training programs to $6.5% ($48 mmol/mol) suggests that
keep staff up to date. Care provided by appropriately trained the onset of diabetes preceded hospitali-
Initial evaluation should state the type specialists or specialty teams may reduce zation (see Section 2, “Diagnosis and

of diabetes (i.e., type 1, type 2, gesta- the length of stay and improve glycemic Classification of Diabetes”). Level 1 hypo-
tional, pancreatogenic, drug related, or and other clinical outcomes (15,16). In ad- glycemia is defined as a glucose concen-
nutrition related) when it is known. Be- dition, the increased risk of 30-day read- tration of 54–69 mg/dL (3.0–3.8 mmol/L).
cause inpatient treatment and discharge mission following hospitalization that has Level 2 hypoglycemia is defined as
planning are more effective when pread- been attributed to diabetes can be re- a glucose concentration <54 mg/dL
mission glycemia is considered, A1C duced, and costs saved, when inpatient (<3.0 mmol/L), which is typically the
care is provided by a specialized diabetes threshold for neuroglycopenic symptoms.
should be measured for all people with
management team (15,17,18). In a cross- Level 3 hypoglycemia is defined as a clini-
diabetes or dysglycemia admitted to the
sectional study comparing usual care to cal event characterized by altered mental
hospital if no A1C test result is available
specialists reviewing diabetes cases and and/or physical functioning that requires
from the previous 3 months (3–6). In
making recommendations virtually through assistance from another person for recov-
addition, diabetes self-management
the EHR, rates of both hyperglycemia and ery (Table 6.4) (25,26). Levels 2 and 3
knowledge and behaviors should be as-
hypoglycemia were reduced by 30–40% require immediate intervention and cor-
sessed on admission, and diabetes self- (19). Providing inpatient diabetes self- rection of low blood glucose. Prompt
management education provided (if management education and developing a treatment of level 1 hypoglycemia is
available), especially if a new treatment diabetes discharge plan that includes con- recommended as an effort to prevent
plan is being considered. Diabetes self- tinued access to diabetes medications progression to more significant level 2
management education should include and supplies and ongoing education and and level 3 hypoglycemia.
knowledge and survival skills needed af- support are key strategies to improve out-
ter discharge, such as medication dosing comes (20,21). Details of diabetes care Glycemic Goals
and administration, glucose monitoring, team composition and other resources In a landmark clinical trial conducted in a
and recognition and treatment of hypo- are available from the Joint Commission surgical intensive care unit (ICU), Van
glycemia (7). Evidence supports pread- accreditation program for the hospital den Berghe et al. (27) demonstrated that
mission treatment of hyperglycemia in care of diabetes, from the Society of Hos- an intensive intravenous insulin protocol
people scheduled for elective surgery as an pital Medicine workbook, and from the with a glycemic goal of 80–110 mg/dL
effective means of reducing adverse out- Joint British Diabetes Societies (JBDS) for (4.4–6.1 mmol/L) reduced mortality by
comes (8–11). Inpatient Care Group (22–24). 40% compared with a standard approach
The National Academy of Medicine rec- of a glycemic goal of 180–215 mg/dL
ommends CPOE to prevent medication- GLYCEMIC GOALS IN (10–12 mmol/L) in critically ill hospitalized
related errors and to increase medication HOSPITALIZED ADULTS individuals with recent surgery. This study
administration efficiency (12). Systematic provided evidence that active treatment
Recommendations
reviews of randomized controlled trials to lower blood glucose in hospitalized in-
using computerized advice to improve 16.4 Insulin A and/or other therapies
B should be initiated or intensified for dividuals could have immediate benefits.
glycemic outcomes in the hospital found However, a large, multicenter follow-up
significant improvement in the percent- treatment of persistent hyperglycemia
starting at a threshold of $180 mg/dL study in critically ill hospitalized individu-
age of time individuals spent in the gly- als, the Normoglycemia in Intensive Care
($10.0 mmol/L) (confirmed on two
cemic goal range, lower mean blood Evaluation and Survival Using Glucose
occasions within 24 h) for noncritically
glucose levels, and no increase in hypo- Algorithm Regulation (NICE-SUGAR) trial
ill (non-ICU) individuals. A
glycemia (13). Where feasible, there (28), led to a reconsideration of the opti-
16.5a Once therapy is initiated, a
should be structured order sets that pro- mal glucose lowering goal in critical illness.
glycemic goal of 140–180 mg/dL
vide computerized guidance for glycemic In this trial, critically ill individuals random-
(7.8–10.0 mmol/L) is recommended
management. Insulin dosing algorithms ized to intensive glycemic management
for most critically ill (ICU) individuals
using machine learning and data in the (80–110 mg/dL [4.4–6.1 mmol/L]) derived
with hyperglycemia. A
electronic health record (EHR) currently no significant treatment advantage
16.5b More stringent glycemic goals, such
in development show promise for pre- compared with a group with more mod-
as 110–140 mg/dL (6.1–7.8 mmol/L),
dicting insulin requirements during erate glycemic goals (140–180 mg/dL
may be appropriate for selected
hospitalization (14). [7.8–10.0 mmol/L]) and had slightly but
diabetesjournals.org/care Diabetes Care in the Hospital S297
significantly higher mortality (27.5% vs. GLUCOSE MONITORING 16.7 For people with diabetes using an
25%). The intensively treated group had In hospitalized individuals with diabetes automated insulin delivery (AID) system
10- to 15-fold greater rates of hypogly- who are eating, point-of-care (POC) blood along with CGM, the use of AID and
cemia, which may have contributed to glucose monitoring should be performed CGM should be continued during hospi-
the adverse outcomes noted. The findings before meals; in those not eating, glucose talization if clinically appropriate, with
from the NICE-SUGAR trial, supported by monitoring is advised every 4–6 h (26). confirmatory POC blood glucose meas-
several meta-analyses and a randomized More frequent POC blood glucose moni- urements for insulin dosing decisions
controlled trial, showed higher rates of hy- toring ranging from every 30 min to every and hypoglycemia assessment, if resour-
poglycemia and an increase in mortality 2 h is the required standard for safe use ces and training are available, and ac-
with more aggressive glycemic manage- of intravenous insulin therapy. cording to an institutional protocol. C
ment goals compared with moderate Hospital blood glucose monitoring should
glycemic goals (29–31). Based on these re- be performed with U.S. Food and Drug Ad-
sults, insulin and/or other therapies should ministration (FDA)–approved POC hospital- Several studies have demonstrated that

be initiated for the treatment of persis- calibrated glucose monitoring systems (35). inpatient use of continuous glucose moni-
tent hyperglycemia $180 mg/dL ($10.0 POC blood glucose meters are not as accu- toring (CGM) has advantages over POC
mmol/L). Once therapy is initiated, a gly- rate or as precise as laboratory glucose ana- glucose monitoring in detecting hypogly-
cemic goal of 140–180 mg/dL (7.8–10.0 lyzers, and capillary blood glucose readings cemia, particularly nocturnal, prolonged
are subject to artifacts due to perfusion, and/or asymptomatic hypoglycemia (39–41),
mmol/L) is recommended for most critically
edema, anemia/erythrocytosis, and several and in reducing recurrent hypoglycemia
ill individuals with hyperglycemia. Although
medications commonly used in the hospital (42,43). However, at this time, initiating
not as well supported by data from random-
(35) (Table 7.1). The FDA has established use of a new CGM device has not been
ized controlled trials, these recommenda-
standards for capillary (finger-stick) POC glu- approved by the FDA. During the corona-
tions have been extended to hospitalized cose monitoring in the hospital (35).The bal-
individuals without critical illness. More virus disease 2019 (COVID-19) pandemic,
ance between analytic requirements (e.g., many institutions used CGM in ICU and
stringent glycemic goals, such as 110–140 accuracy, precision, and interference) and
mg/dL (6.1–7.8 mmol/L), may be appropri- non-ICU settings, with the aim of mini-
clinical requirements (e.g., rapidity, simplic- mizing exposure time and saving personal
ate for selected individuals (e.g., critically ill ity, and POC) has not been uniformly re-
individuals undergoing surgery) if it can be protective equipment, under an FDA pol-
solved (35–38), and most hospitals have icy of enforcement discretion (44,45). Data
achieved without significant hypoglycemia arrived at their own policies to balance on the safety and efficacy of real-time
(32,33). these parameters. It is critically important CGM use in the hospital, particularly with
For inpatient management of hypergly- that devices selected for in-hospital use, and
implementation of remote monitoring
cemia in noncritical care settings, a glycemic the workflow through which they are ap-
(e.g., a glucose telemetry system), is
goal of 100–180 mg/dL (5.6–10.0 mmol/L) plied, undergo careful analysis of perfor-
growing (42,43,45–50).
is recommended, whether it is new hyper- mance and reliability and ongoing quality
Continuation of personal CGM device
glycemia (e.g., newly diagnosed diabetes assessments (38). Recent studies indicate
use, particularly for people with type 1 or
or stress hyperglycemia) or hyperglycemia that POC measures provide adequate infor-
type 2 diabetes treated with intensive ther-
related to diabetes prior to admission (2). mation for usual practice, with only rare in-
apy at increased risk for hypoglycemia
It has been found that fasting glucose stances where care has been compromised
during hospitalization, is recommended.
levels <100 mg/dL (<5.6 mmol/L) are (36,37). Best practice dictates that any glu-
Confirmatory POC capillary glucose test-
predictors of hypoglycemia within the cose result that does not correlate with the
ing, using hospital-calibrated glucose me-
next 24 h (34). Glycemic levels up to 250 individual’s clinical status should be con-
ters, is recommended for insulin dosing
mg/dL (13.9 mmol/L) may be acceptable firmed by measuring a sample in the clinical
laboratory, particularly for asymptomatic hy- and hypoglycemia assessment (e.g., hy-
in selected populations (terminally ill indi- brid testing protocols) (51). People with
viduals with short life expectancy, ad- poglycemic events.
diabetes should be counseled about
vanced kidney failure [and/or on dialysis], meaningful use of trend arrows and
high risk for hypoglycemia, and/or labile Continuous Glucose Monitoring alarms and about notifying nursing staff
glycemic excursions). In these individu- for confirmation of these events with
Recommendations
als, less aggressive treatment goals that 16.6 In people with diabetes using a POC capillary glucose testing. Similarly,
would help avoid symptomatic hypogly- personal continuous glucose monitor- continuation of AID systems should be
cemia and/or hyperglycemia are often ing (CGM) device, the use of CGM supported during hospitalization, when
appropriate. Clinical judgment combined should be continued during hospitali- clinically appropriate, and with proper
with ongoing assessment of clinical sta- zation if clinically appropriate, with staff training and supervision (41,45). Ob-
tus, including changes in the trajectory of confirmatory point-of-care (POC) glu- servational studies have demonstrated
glucose measures, illness severity, nutri- cose measurements for insulin dosing improvements in patient satisfaction and
tional status, or concomitant medications decisions and hypoglycemia assess- improved detection of glycemic excursions
that might affect glucose levels (e.g., gluco- ment, if resources and training are (40,47). If the reason for admission is sus-
corticoids), may be incorporated into the available, and according to an institu- pected to be related to device malfunction
day-to-day decisions regarding treatment tional protocol. B or lack of adequate education/training or
dosing. use, consultation with the endocrinology/
diabetes care team or diabetes care and hyperosmolar state (HHS) management, correction or supplemental insulin without
education specialists, if available, is rec- continuous intravenous insulin infusion is basal insulin as the sole treatment of hy-
ommended. Hospitals are encouraged to given for correction of hyperglycemia, hyper- perglycemia is strongly discouraged in the
develop institutional policies and have ketonemia, and acid-base disorder following inpatient setting, with the exception of
trained personnel with knowledge of dia- a fixed-rate intravenous insulin infusion (53) people with type 2 diabetes in noncritical
betes technology. Recent review articles or nurse-driven protocol with a variable rate care with mild hyperglycemia (2,64,65).
provide details on accuracy, interfer- based on glucose values (54). Individuals A prospective randomized inpatient
ences, precautions, and contraindications with mild and uncomplicated DKA can be study of 70/30 intermediate-acting (NPH)/
of diabetes technology devices in the managed with subcutaneous rapid-acting in- regular insulin mixture versus basal-bolus
hospital setting (50,51). sulin doses given every 1–2 h (55). therapy showed comparable glycemic out-
For more information on CGM, see comes but significantly increased hypogly-
Section 7, “Diabetes Technology.” Noncritical Care Setting cemia in the group receiving insulin mixture
In most instances, insulin is the preferred (66). Therefore, insulin mixtures such as 75/

GLUCOSE-LOWERING TREATMENT treatment for hyperglycemia in hospital- 25, 70/30, or 50/50 insulins are not rou-
IN HOSPITALIZED PATIENTS ized individuals. In certain circumstances, tinely recommended for in-hospital use.
An individualized approach for glycemic it may be appropriate to continue home Data on the use of glargine U-300
oral glucose-lowering medications, such and degludec U-100 or U-200 in the in-
management is encouraged throughout
as dipeptidyl peptidase 4 inhibitors (DPP-4i) patient and perioperative settings are
the hospital stay and should take into
(52,56). If oral medications are held in the limited. A few studies have shown that
consideration several predictive factors
hospital but will be reinstated after dis- they demonstrated similar efficacy and
for achieving glycemic goals, such as
charge, there should be a protocol for safety compared with glargine U-100
prior home use and dose of insulin or
guiding resumption of home medications (67–69). At this time, there is no avail-
noninsulin therapy, expected level of in-
1–2 days prior to discharge. For people able evidence for weekly insulin use in
sulin resistance, prior A1C, current glu-
taking insulin, several reports indicate that hospital or surgical settings.
cose levels, oral intake, and duration of
inpatient use of insulin pens is safe and
diabetes.
may improve nurse satisfaction when Type 1 Diabetes
safety protocols, including nursing edu- For people with type 1 diabetes, dosing
Insulin Therapy
cation, are in place to guarantee single- insulin based solely on premeal glucose
Recommendations person use (57–61). levels does not account for basal insulin
16.8 Basal insulin or a basal plus bolus Outside of critical care units, scheduled requirements or caloric intake, increasing
correction insulin plan is the preferred subcutaneous insulin orders are recom- the risk of both hypoglycemia and hyper-
treatment for noncritically ill hospital- mended for the management of hyperglycemia. Typically, basal insulin dosing is
ized individuals with poor oral intake glycemia in people with diabetes and based on body weight and expected sen-
or those who are taking nothing by hyperglycemia. Use of insulin analogs or sitivity to insulin, with some evidence
mouth. A human insulin results in similar glycemic that people with renal insufficiency
16.9 An insulin plan with basal, pran- outcomes in the hospital setting but may should be treated with lower insulin
dial, and correction components is the increase severe hypoglycemic events (62). doses (70,71). An insulin schedule with
preferred treatment for most noncriti- The use of subcutaneous rapid- or short- basal and correction components is nec-
cally ill hospitalized individuals with acting insulin before meals, or every 4–6 h essary for all hospitalized individuals with
adequate nutritional intake. A if no meals are given or if the individual is type 1 diabetes, even when taking noth-
16.10 Sole use of a correction or receiving continuous enteral/parenteral ing by mouth, with the addition of pran-
supplemental insulin without basal nutrition, is indicated to correct or pre- dial insulin when eating. Policies and best
insulin (formerly referred to as a vent hyperglycemia. Basal insulin, or a practice alerts in the EHR should be put in
sliding scale) in the inpatient setting basal plus bolus correction schedule, is place to ensure that basal insulin (given
is discouraged. A the preferred treatment for noncritically subcutaneously, via insulin pump or by in-
ill hospitalized individuals with inadequate sulin infusion) is not held for people with
or restricted oral intake. An insulin sched- type 1 diabetes, especially during care
Critical Care Setting ule with basal, prandial, and correction transitions, and that ongoing prescriber
Continuous intravenous insulin infusion components is the preferred treatment and nursing education is provided (60).
is the most effective method for achiev- for most noncritically ill hospitalized people
ing specific glycemic goals and avoiding with diabetes with adequate nutritional Transitioning From Intravenous to
hypoglycemia in the critical care setting. intake. Subcutaneous Insulin
Intravenous insulin infusions should be A randomized controlled trial has shown When discontinuing intravenous insulin, a
administered using validated written or that basal plus bolus treatment improved transition protocol is recommended, as it
computerized protocols that allow for glycemic outcomes and reduced hospital is associated with less morbidity and
predefined adjustments in the insulin in- complications compared with a correction lower costs of care. Subcutaneous basal
fusion rate based on glycemic fluctua- or supplemental insulin without basal insu- insulin should be given 2 h before intrave-
tions and immediate past and current lin (formerly known as sliding scale) for nous infusion is discontinued, with the
insulin infusion rates (52). For diabetic people with type 2 diabetes admitted for aim of minimizing rebound hyperglycemia
ketoacidosis (DKA) and hyperglycemic general surgery (63). Prolonged use of (2,72,73).
Emerging data from several studies if there are no contraindications and after plan be reviewed any time a blood glucose
show that the administration of a low dose recovery from the acute illness (88,89). value of <70 mg/dL (<3.9 mmol/L) occurs,
(0.15–0.3 units/kg) of basal insulin analog SGLT2 inhibitors should be avoided in cases as this level often predicts subsequent level
in addition to intravenous insulin infusion of severe illness, in people with ketonemia 3 hypoglycemia (99). Episodes of hypoglyce-
may reduce the duration of insulin infusion or ketonuria, and during prolonged fasting mia in the hospital should be documented
and length of hospital stay and prevent re- and surgical procedures (90–93). Proac- in the EHR and tracked (1). A key strategy is
bound hyperglycemia without increased tive adjustment of diuretic dosing is rec- embedding hypoglycemia treatment into all
risk of hypoglycemia (74–76). ommended during hospitalization and/or insulin and insulin infusion orders.
For transitioning, the total daily dose of discharge, especially in collaboration with
subcutaneous insulin can be calculated a cardiology/heart failure consult team Inpatient Hypoglycemia: Risk
based on the insulin infusion rate during (90–93). The FDA has warned that SGLT2 Factors, Treatment, and Prevention
the prior 6–8 h when stable glycemic goals inhibitors should be stopped 3 days before Insulin is one of the most common medi-
were achieved, based on prior home insulin scheduled surgeries (4 days in the case of cations causing adverse events in hospital-

dose, or following a weight-based approach ertugliflozin) (94). ized individuals. Errors in insulin dosing,
(72,73). For people being transitioned to missed doses, and/or administration errors
concentrated insulin (U-200, U-300, or HYPOGLYCEMIA including incorrect insulin type and incor-
U-500) in the inpatient setting, it is impor- rect timing of dose occur relatively fre-
Recommendations quently (100–102) and include prescriber
tant to ensure correct dosing by using a sep-
arate pen or vial for each person and by 16.12 A hypoglycemia management (ordering), pharmacy (dispensing), and
meticulous pharmacy and nursing supervi- protocol should be adopted and imple- nursing (administration) errors. Common
sion of the dose administered (77,78). mented by each hospital or hospital preventable sources of iatrogenic hypogly-
system. A plan for preventing and treat- cemia are improper prescribing of other
Noninsulin Therapies
ing hypoglycemia should be established glucose-lowering medications and inap-
for each individual. Episodes of hypo- propriate management and follow-up of
Recommendation glycemia in the hospital should be the first episode of hypoglycemia (103). Kid-
16.11 For people with type 2 diabetes documented in the electronic health ney failure is an important risk factor for hy-
hospitalized with heart failure, it is record and tracked for quality assess- poglycemia in the hospital (104), possibly
recommended that use of a sodium– ment and quality improvement. E as a result of decreased insulin clearance.
glucose cotransporter 2 inhibitor be 16.13 Treatment plans should be re- Studies of “bundled” preventive therapies,
initiated or continued during hospital- viewed and changed as necessary to including proactive surveillance of glycemic
ization and upon discharge, if there outliers and an interdisciplinary data-driven
prevent hypoglycemia and recurrent
are no contraindications and after re- approach to glycemic management, showed
hypoglycemia when a blood glucose
covery from the acute illness. A
value of <70 mg/dL (<3.9 mmol/L) is that hypoglycemic episodes in the hospi-
documented. C tal could be reduced or prevented. Com-
pared with baseline, studies found that
The safety and efficacy of noninsulin hypoglycemic events decreased by
glucose-lowering therapies in the hospital People with or without diabetes may ex- 56–80% (98,105,106). The Joint Commis-
setting has expanded recently (79–83). A perience hypoglycemia in the hospital sion, a global quality improvement and
randomized trial and an observational study setting. While hypoglycemia is associated patient safety in health care organiza-
have demonstrated the safety and efficacy with increased mortality (95,96), in many tion, recommends that all hypoglycemic
of DPP-4i in specific groups of hospitalized cases, it is a marker of an underlying dis- episodes be evaluated for a root cause
people with diabetes (84,85). The use of ease rather than the cause of fatality. and the episodes be aggregated and re-
DPP-4i with or without basal insulin may be However, hypoglycemia is a severe conse- viewed to address systemic issues (23).
a safer and simpler plan for people with quence of dysregulated metabolism and/or In addition to errors with insulin treatment,
mild to moderate hyperglycemia on admis- diabetes treatment, and it is imperative iatrogenic hypoglycemia may be induced by a
sion (e.g., admission glucose <180–200 that it be minimized during hospitalization. sudden reduction of corticosteroid dose,
mg/dL), with reduced risk of hypoglycemia Many episodes of inpatient hypoglycemia reduced oral intake, emesis, inappropriate
(79,85,86). Of note, the FDA states that are preventable. A hypoglycemia preven- timing of short- or rapid-acting insulin
health care professionals should consider tion and management protocol should be doses in relation to meals, reduced infusion
discontinuing saxagliptin and alogliptin in adopted and implemented by each hos- rate of intravenous dextrose, unexpected
people who develop heart failure (87). Data pital or hospital system. A standardized interruption of enteral or parenteral feedings,
on the inpatient use of glucagon-like pep- hospital-wide, nurse-initiated hypoglycemia delayed or missed blood glucose checks, and
tide 1 (GLP-1) receptor agonists are still treatment protocol should be in place to altered ability of the individual to report
mostly limited to research studies and select immediately address blood glucose levels symptoms (107).
populations that are medically stable (83). <70 mg/dL (<3.9 mmol/L) (97,98). In addi- Recent inpatient studies show promise
For people with type 2 diabetes hospital- tion, individualized plans for preventing for CGM as an early warning system to
ized with heart failure, it is recommended and treating hypoglycemia for each individ- alert of impending hypoglycemia, offering
that use of a sodium–glucose cotransporter ual should also be developed. An American an opportunity to mitigate it before it hap-
2 (SGLT2) inhibitor be initiated or continued Diabetes Association consensus statement pens (46–49). The use of personal CGM
during hospitalization and upon discharge, recommends that an individual’s treatment and AID devices, such as insulin pumps
that can automatically deliver correction calories to meet metabolic demands, opti- wish to take their own or hospital-dispensed
doses and change basal delivery rates in mize glycemic outcomes, address personal insulin and noninsulin injectable medica-
real time, should be supported for ongo- food preferences, and facilitate the crea- tions during their hospital stay. A hospital
ing use during hospitalization for individu- tion of a discharge plan. The American Di- policy for personal medication may consider
als who are capable of using their devices abetes Association does not endorse any a pharmacy exception on a case-by-case ba-
safely and independently when proper single meal plan or specified percentages sis along with the care team. Pharmacy
oversight supervision is available. Hospi- of macronutrients. Current nutrition rec- must verify any home medication and re-
tals should be encouraged to develop poli- ommendations advise individualization quire a prescriber order for the individual
cies and protocols to support inpatient based on treatment goals, physiological to self-administer home or hospital-
use of individual- and hospital-owned dia- parameters, and medication use. Con- dispensed medication under the su-
betes technology and have expert staff trolled carbohydrate meal plans, where pervision of the registered nurse. If an
available for safe implementation and the amount of carbohydrate on each insulin pump or CGM device is worn,
evaluation of continued use during the meal tray is calculated, are preferred by hospital policy and procedures delin-

hospital stay (51). Hospital information many hospitals, as they facilitate match- eating guidelines for wearing an insulin
technology teams are beginning to inte- ing the prandial insulin dose to the pump and/or CGM device should be de-
grate CGM data into the EHR. The ability amount of carbohydrate given (114). Or- veloped according to consensus guide-
to download and interpret diabetes de- ders should also indicate that the meal lines, including the changing of insulin
vice data during hospitalization can inform delivery and nutritional insulin coverage infusion sites and CGM glucose sensors
insulin dosing during hospitalization and should be coordinated, as their variability (41,120,121). As outlined in Recommenda-
care transitions (41). often creates the possibility of hypergly- tions 7.33 and 7.34, people with diabetes
For more information on CGM, see cemic and hypoglycemic events (20). wearing diabetes devices should be sup-
Section 7, “Diabetes Technology.” Some hospitals offer “meals on demand,” ported to continue them in an inpatient
where individuals may order meals from setting if they are assessed and deemed
Predictors of Hypoglycemia the menu at any time during the day. This competent to perform self-care and proper
In people with diabetes, it is well established option improves patient satisfaction but supervision is available.
that an episode of severe hypoglycemia in- complicates insulin–meal coordination
creases the risk for a subsequent event, and can lead to insulin stacking if meals STANDARDS FOR SPECIAL
partly because of impaired counterregula- are too close together. Finally, if the hos- SITUATIONS
tion (108,109). In a study of hospitalized pital food service supports carbohydrate Enteral/Parenteral Feedings
individuals, 84% of people who had an epi- counting, this option should be made For individuals receiving enteral or parenteral
sode of severe hypoglycemia (defined as available to people with diabetes count- feedings who require insulin, the insulin or-
<40 mg/dL [<2.2 mmol/L]) had a preced- ing carbohydrates at home and people ders should include coverage of basal, pran-
ing episode of hypoglycemia (<70 mg/dL wearing insulin pumps (115,116). dial, and correctional needs (115,122,123).
[<3.9 mmol/L]) during the same admis- It is essential that people with type 1 diabe-
sion (110). In another study of hypoglyce- SELF-MANAGEMENT IN THE tes continue to receive basal insulin even if
mic episodes (defined as <50 mg/dL HOSPITAL feedings are discontinued.
[<2.8 mmol/L]), 78% of individuals were Diabetes self-management in the hospital Most adults receiving basal insulin
taking basal insulin, with the incidence of may be appropriate for specific individuals should continue with their basal dose,
hypoglycemia peaking between midnight who wish to continue to perform self-care while the insulin dose for the total daily
and 6:00 A.M. Despite recognition of hypo- while acutely ill (117–119). Candidates in- nutritional component may be calculated
glycemia, 75% of individuals did not have clude children with parental supervision, as 1 unit of insulin for every 10–15 g of
their dose of basal insulin changed before adolescents, and adults who successfully carbohydrate in the enteral and paren-
the next basal insulin administration (111). perform diabetes self-management at teral formulas. Commercially available
Recently, several groups have devel- home and whose cognitive and physical cans of enteral nutrition contain variable
oped algorithms to predict episodes of skills needed to successfully self-administer amounts of carbohydrates and may be
hypoglycemia in the inpatient setting insulin and perform glucose monitoring are infused at different rates.
(112,113). Models such as these are po- not compromised (7,41). In addition, they All of this must be considered when
tentially important and, once validated should have adequate oral intake, be profi- calculating insulin doses to cover the nu-
for general use, could provide a valu- cient in carbohydrate estimation, take mul- tritional component of enteral nutrition
able tool to reduce rates of hypoglyce- tiple daily insulin injections or wear insulin (116). Giving NPH insulin two or three
mia in the hospital. In one retrospective pumps, have stable insulin requirements, times daily (every 8 or 12 h) to cover indi-
cohort study, a fasting blood glucose of and understand sick-day management. If vidual requirements is a reasonable op-
<100 mg/dL was shown to be a predic- self-management is supported, a policy tion. Adjustments in insulin doses should
tor of next-day hypoglycemia (34). should include a requirement that people be made frequently. Correctional insulin
with diabetes and the care team agree should also be administered subcutane-
MEDICAL NUTRITION THERAPY IN that self-management is appropriate on a ously every 6 h with regular human insu-
THE HOSPITAL daily basis during hospitalization. Hospital lin. If enteral nutrition is interrupted, a
The goals of medical nutrition therapy personal medication policies may include dextrose infusion should be started im-
in the hospital are to provide adequate guidance for people with diabetes who mediately to prevent hypoglycemia and
to allow time to determine more appro- but frequently reach blood glucose goals heart disease and those with auto-
priate insulin doses. overnight regardless of treatment (125). In nomic neuropathy or renal failure.
For adults receiving enteral bolus feed- individuals on once- or twice-daily steroids, 2. The A1C goal for elective surgeries
ings, approximately 1 unit of regular human administering NPH insulin is a standard should be <8% (<63.9 mmol/L) when-
insulin or rapid-acting insulin per every approach. NPH is usually administered in ever possible.
10–15 g of carbohydrate should be given addition to daily basal-bolus insulin or in 3. The blood glucose goal in the periopera-
subcutaneously before each feeding.To mit- addition to oral glucose-lowering medica- tive period should be 100–180 mg/dL
igate any hyperglycemia, correctional insu- tions, depending on the type of diabetes (5.6–10.0 mmol/L) (135) within 4 h
lin should be added as needed before each and recent diabetes medication prior to of the surgery. CGM should not be
feeding. starting steroids. Because NPH action used alone for glucose monitoring dur-
In individuals receiving nocturnal tube peaks about 4–6 h after administration, it ing surgery (138).
feeding, NPH insulin administered along 4. Metformin should be held on the
is recommended that it be administered
with the initiation of the feeding is a rea- day of surgery.

concomitantly with intermediate-acting
sonable approach to cover this nutritional 5. SGLT2 inhibitors should be discon-
steroids (129). For long-acting glucocorti-
load. tinued 3–4 days before surgery.
coids such as dexamethasone and multi-
For individuals receiving continuous pe- 6. Hold other oral glucose-lowering agents
dose or continuous glucocorticoid use, the morning of surgery or procedure
ripheral or central parenteral nutrition, long-acting basal insulin may be required
human regular insulin may be added to and give one-half of NPH dose or
to manage fasting blood glucose levels 75–80% doses of long-acting analog in-
the solution, particularly if >20 units of (53,130). For higher doses of glucocorti-
correctional insulin have been required in sulin or adjust insulin pump basal rates
coids, increasing doses of prandial (if eat- based on the type of diabetes and clini-
the past 24 h. A starting dose of 1 unit of
ing) and correction insulin, sometimes as cal judgment.
regular human insulin for every 10 g of
much as 40–60% or more, are often 7. Monitor blood glucose at least every
dextrose has been recommended (105)
needed in addition to basal insulin 2–4 h while the individual takes noth-
and should be adjusted daily in the solu-
(131,132). A retrospective study found ing by mouth and dose with short- or
tion. Adding insulin to the parenteral nu-
that increasing the ratio of insulin to rapid-acting insulin as needed.
trition bag is the safest way to prevent
steroids was positively associated with 8. There are little data on the safe use
hypoglycemia if the parenteral nutrition is
improved time in range (70–180 mg/dL); and/or influence of GLP-1 receptor
stopped or interrupted. Correctional insu-
however, there was an increase in hypo- agonists on glycemia and delayed
lin should be administered subcutane-
glycemia (133). If insulin orders are initi- gastric emptying in the perioperative
ously to address any hyperglycemia.
ated, daily adjustments based on levels period.
Because continuous enteral or parenteral
of glycemia and anticipated changes in 9. Stricter perioperative glycemic goals
nutrition results in a continuous postpran-
type, dosages, and duration of glucocor- are not advised, as perioperative glyce-
dial state, efforts to bring blood glucose
ticoids, along with POC blood glucose mic goals stricter than 80–180 mg/dL
levels to below 140 mg/dL (7.8 mmol/L)
monitoring, are critical to reducing hypo- (4.4–10.0 mmol/L) may not improve
substantially increase the risk of hypoglyce-
glycemia and hyperglycemia. outcomes and are associated with
mia in these individuals. For full enteral/
more hypoglycemia (137).
parenteral feeding guidance, please refer 10. Compared with usual dosing, a reduc-
to randomized controlled trials detailing Perioperative Care
It is estimated that up to 20% of individu- tion by 25% of basal insulin given the
this topic (122,124). evening before surgery is more likely
als undergoing general surgery have dia-
betes, and 23–60% have prediabetes or to achieve perioperative blood glucose
Glucocorticoid Therapy goals with a lower risk for hypoglyce-
The prevalence of consistent use of gluco- undiagnosed diabetes. Surgical stress and
mia (139).
corticoid therapy in hospitalized individuals counterregulatory hormone release in-
11. In individuals undergoing noncardiac
can approach 10–15%, and these medica- crease the risk of hyperglycemia as well
general surgery, basal insulin plus
tions can induce hyperglycemia in 56–86% as mortality, infection, and length of stay
premeal short- or rapid-acting insulin
of these individuals with and without (134–136). There are little data available
(basal-bolus) coverage has been
preexisting diabetes (125–127). If left un- to guide care of people with diabetes associated with improved glycemic out-
treated, this hyperglycemia increases mor- through the perioperative period. To reduce comes and lower rates of perioperative
tality and morbidity risk, e.g., infections surgical risk in people with diabetes, some complications compared with the re-
and cardiovascular events. Glucocorticoid institutions (135,137,138) have A1C cutoffs active, correction-only short- or rapid-
type and duration of action must be con- for elective surgeries, and some have devel- acting insulin coverage alone with no
sidered in determining appropriate insulin oped optimization programs to lower A1C basal insulin dosing (63,134,135).
treatments. Daily-ingested intermediate- prior to surgery (134,135,137,138).
acting glucocorticoids such as prednisone The following approach (134,135,137) Diabetic Ketoacidosis and
reach peak plasma levels in 4–6 h (128) may be considered: Hyperglycemic Hyperosmolar State
but have pharmacologic actions that can There is considerable variability in the
last throughout the day. Individuals placed 1. A preoperative risk assessment should presentation of DKA and HHS, ranging
on morning steroid therapy have dispro- be performed for people with diabe- from euglycemia or mild hyperglycemia
portionate hyperglycemia during the day tes who are at high risk for ischemic and acidosis to severe hyperglycemia,
dehydration, and coma; therefore, indi- A structured discharge plan tailored to Medication Reconciliation
vidualization of treatment based on a the individual may reduce the length of • Home and hospital medications must
careful clinical and laboratory assess- hospital stay and readmission rates and be cross-checked to ensure that no
ment is needed (75,140–142). increase satisfaction with the hospital ex- chronic medications are stopped and
Management goals include restoration perience (147). Multiple strategies are to ensure the safety of new and old
of circulatory volume and tissue perfusion, key, including diabetes self-management prescriptions.
resolution of ketoacidosis, and correction education prior to discharge, diabetes • Prescriptions for new or changed medi-
of electrolyte imbalance and acidosis. It is medication reconciliation with attention cation should be filled and reviewed
also essential to treat any correctable un- to access, and scheduled virtual and/or with the individual and care partners at
derlying cause of DKA, such as sepsis, myo- face-to-face follow-up visits after discharge. or before discharge.
cardial infarction, or stroke. In critically ill Discharge planning should begin at admis-
and mentally obtunded individuals with sion and be updated as individual needs Structured Discharge
DKA or HHS, continuous intravenous insu- change (148,149). Communication

lin is the standard of care. Successful transi- The transition from the acute care set- • Information on medication changes,
tion from intravenous to subcutaneous ting presents risks for all people with dia- pending tests and studies, and follow-up
insulin requires administration of basal in- betes. Individuals may be discharged to needs must be accurately and promptly
sulin 2–4 h before the intravenous insu- varied settings, including home (with or communicated to outpatient health care
lin is stopped to prevent recurrence of without visiting nurse services), assisted professionals.
ketoacidosis and rebound hyperglyce- living, rehabilitation, or skilled nursing fa- • Discharge summaries should be trans-
mia (72,73,140). Recent studies have cilities. For individuals discharged to home mitted to the primary care clinician as
reported that the administration of a or assisted living, the optimal discharge soon as possible after discharge.
low dose of basal insulin analog in addi- plan will need to consider diabetes type • Scheduling follow-up appointments
tion to intravenous insulin infusion may and severity, effects of the illness on blood prior to discharge with people with dia-
prevent rebound hyperglycemia without in- glucose levels, and the individual’s cir- betes agreeing to the time and place
creased risk of hypoglycemia (74–76,140).
cumstances, capabilities, and preferen- increases the likelihood that they will
There is no significant difference in out-
ces (21,150,151). See Section 13, “Older attend.
comes for intravenous human regular
Adults,” for more information. It is recommended that the following
insulin versus subcutaneous rapid-acting
An outpatient follow-up visit with the areas of knowledge be reviewed and ad-
analogs when combined with aggressive
primary care clinician, endocrinologist, or dressed before hospital discharge:
fluid management for treating mild or
diabetes care and education specialist
moderate DKA (143). Individuals with
uncomplicated DKA may sometimes be
within 1 month of discharge is advised for • Identification of the health care profes-
all individuals experiencing hyperglycemia sionals who will provide diabetes care
treated with subcutaneous rapid-acting
and/or hypoglycemia in the hospital. If gly- after discharge.
insulin analogs in the emergency depart-
ment or step-down units (144). This ap-
cemic medications are changed or glucose • Level of understanding related to the
proach may be safer and more cost- management is not optimal at discharge, diabetes diagnosis, glucose monitoring,
effective than treatment with intravenous an earlier appointment (in 1–2 weeks) is home glucose goals, and when to call a
insulin. If subcutaneous insulin adminis- preferred, and frequent contact may be health care professional.
tration is used, it is important to provide needed to avoid hyperglycemia and hypo- • Definition, recognition, treatment, and
an adequate fluid replacement, frequent glycemia. A discharge algorithm for gly- prevention of hyperglycemia and
POC blood glucose monitoring, treatment cemic medication adjustment, based on hypoglycemia.
of any concurrent infections, and appro- admission A1C, diabetes medications be- • Information on making healthy food
priate follow-up to avoid recurrent DKA. fore admission, and insulin usage during choices at home and referral to an out-
Several studies have shown that the use hospitalization was found useful to guide patient registered dietitian nutritionist
of bicarbonate in people with DKA treatment decisions and significantly im- or diabetes care and education special-
made no difference in the resolution prove A1C after discharge (4). ist to guide individualization of the
of acidosis or time to discharge, and its Clear communication with outpatient meal plan, if needed.
use is generally not recommended health care professionals directly or via • When and how to take blood glu-
(145). For further treatment information, hospital discharge summaries facilitates cose-lowering medications, including
refer to recent in-depth reviews (53, safe transitions to outpatient care. Provid- insulin administration and noninsulin
107,146). ing information regarding the root cause injectables.
of hyperglycemia (or the plan for determin- • Sick-day management (21,151).
ing the cause), related complications and • Proper use and disposal of diabetes
TRANSITION FROM THE HOSPITAL
comorbidities, and recommended treat- supplies, e.g., insulin pen, pen needles,
TO THE AMBULATORY SETTING
ments can assist outpatient health care syringes, and lancets.
Recommendation professionals as they assume ongoing care.
16.14 A structured discharge plan The Agency for Healthcare Research People with diabetes must be pro-
should be tailored to the individual and Quality recommends that, at a min- vided with appropriate durable medical
with diabetes. B imum, discharge plans include the fol- equipment, medications, supplies (e.g.,
lowing (152): blood glucose test strips or CGM
sensors), prescriptions, and appropriate 4. Umpierrez GE, Reyes D, Smiley D, et al. enabled diabetes survival skills education within
education at the time of discharge to Hospital discharge algorithm based on admission nursing unit workflow in an urban, tertiary care
HbA1c for the management of patients with type hospital. Jt Comm J Qual Patient Saf 2021;47:
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Diabetes Care Volume 47, Supplement 1, January 2024 S295

16. Diabetes Care in the Hospital: American Diabetes Association

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Among hospitalized individuals, hyperglycemia, hypoglycemia, and glucose variability

HOSPITAL CARE DELIVERY STANDARDS

process improvement. Unfortunately, “best Diabetes Care Specialists in the

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