Hospitalization Flashcards
When should an A1c be performed on hospitalized patient?
- on all PWD IF they do not have A1c within past 4 months
- in those w/ hyper BG >140
How should insulin be administered in hospital setting?
Use computerized physician order sets
structured order sets provide computerized advice for glycemic control
The validated protocol should allow for predefined adjustments in insulin dose based on glu fluctuations
What DSME should be provided during hospitalization?
- skills needed after d/c
- medication dosing & administration
- glucose monitoring
- ID and treat hypo
Why are DM specialist team in hospital helpful?
Reduce LOS Improve GLU control Improve overall outcomes Increase cost savings Reduce 30 day readmission
When to initiate insulin in hospitalized pt?
BG >/= 180
Once insulin is started what is the target range in most hosptialized patients?
140-180
Who has stricter BG hospital targets?
post surgery, cardiac surgery
110-140
How is HYPER defined in hospital?
BG >140
can change their diet or start meds
What does A1c >/= 6.5% at admission show?
pre-existing DM
Why is tighter glycemic control NOT recommended in hospital?
increase mortality and hypo
Who will have higher hospital BG targets >180
terminally ill
severe comorbidities
inpt settings where frequent BG monitoring not possible
When should BG be checked bedside?
IF eating- before meals
IF not eating- every 4-6 hours (ex:NPO)
How often should pt on insulin drip be monitored?
30 minutes-2 hours
CMG is how many minutes delayed compared to finer prick?
15
If pt is going to be d/c soon, when should they resume their oral meds
1-2 days before d/c
If pt is NPO or eating poorly, what insulin regimen should they be on?
Basal or basal plus bolus
If pt is eating well and not critically ill, what insulin should they be on?
Basal, prandial, correction factor
WHat is MOST effective method of achieving glycemic targets in hospital
IV insulin
If patient is eating, when to inject insulin
immediately before meals
If patient is not eating much
give insulin after meal and adjust dose to how much they are
What is basal insulin dose based on
body weight
All T1DM pts in hospital should get
basal + correction dose
and prandial insulin if they’re eating
How to transition from IV insulin to subq
2-4 hours before stopping IV insulin give subq injection
convert to basal insulin at 60-80% daily infusion dose
When should pt med regimen be reviewed?
any time BG <70
preventable sources of hypo in hospital
- not managing 1st hypo event
- nutrition/insulin mismatch
- sudden reduction in corticosteroid
- reduced oral intake
- emesis
- incorrect timing of rapid or short acting insulin
- interruption of enteral or parenteral feeds
- altered ability to voice s/s hypo
Why is hypo in hospital so concerning
can cause morality
can increase risk for another hypo event d/t impaired counterregulatory response
Goals of MNT in hospital
adequate kcal
optimize glu control
food preferences
d/c plan for each individual
enteral feedings
DM specific formulas are superior
better PP glucose levels
better A1c
insulin response
Correction insulin dosing
human insulin- q 6 hours
rapid acting insulin- q 4 hours
enteral bolus feeds
1 unit regular human insulin per 10-15 g CHO given subQ before each feeding
parenteral feeds
1 unit human insulin for q 10 g dextrose, adjust daily, can add human insulin to the solution but give correction doses subq
perioperative care
goal: 80-180
hold metformin day of surgery
give 1/2 NPH dose or 60-80% long acting insulin
hold other oral meds
monitor BG q 4-6 hours while NPO, can give short or rapid acting insulin if needed
DKA/HHS goals
resolve hyper
correct acidosis and electrolyte imbalances
treat underlying cause of DKA (sepsis, MI, stroke)
restore circulatory volume
treating DKA/HHS
IV insulin is top choice
BUT if not using IV, provide adequate fluids, frequent bedside testing
Do NOT give bicarbonate
why are d/c plans helpful
reduce LOS
lower readmission rate
increase pt satisfaction
should start at admission and be updated throuhout
When should pt be followed after d/c from hospital?
1 month of d/c OR
if meds were changed/glu control remained inadequate, w/in 1-2 weeks
Agency for healthcare research and quality discharge recs:
- medication reconcilliation structured d/c communication ID HC provider post d/c recognize and treat hyper and hypo refer to outpatient RD how and when to take meds sick day mgmt proper use and disposal of needles/syringes
hospital readmission rate in DM is
15-20%; 2x higher than non diabetes
what factors increase readmission rate
male longer LOS # of previous hospitalizations # and severity of complications lower SES/education status advanced age
Factors that d/c readmission rate
scheduled home health visits
timely outpt f/u
use of transitional care model
