In response to the ongoing challenges faced by hospitalized patients requiring insulin therapy, the American Diabetes Association (ADA) released its updated 2024 Standards of Care of Hospitalized Patients this month.

Thirty to forty percent of hospitalized patients require insulin therapy to achieve acceptable glycemic control. This can be difficult when considering the challenges that may be present in the hospital setting, including:

• poor or restricted oral intake
• variations in the timing and quantity of carbohydrate intake
• lack of provider attention to glycemic control due to the presence of multiple comorbidities
• knowledge gaps amongst many members of the healthcare team

The 2024 Standards of Care of Hospitalized Patients adopted by the American Diabetes Association (ADA) are straightforward and limited in number, however without proper protocols and staff education they can be difficult to achieve.

In this discussion we review several of these standards and highlight how EndoTool, a computerized insulin dosing software, streamlines the process. Designed to deliver patient-specific dosing for intravenous (ETIV) or subcutaneous (ETSQ) insulin therapy, EndoTool makes achievement of these standards more straightforward than traditional insulin dosing methods.

Key Points: ADA Standards for Inpatient Diabetes Management

A. Hospital Care Delivery Standards

Recommendations

• Perform an A1C test on all people with diabetes or hyperglycemia (blood glucose >140 mg/dL [7.8 mmol/L]) admitted to the hospital if not performed in the prior three months.
• Insulin should be administered using validated written or computerized protocols for management of dysglycemia in the hospital (including emergency department, intensive care unit [ICU] and non-ICU wards, gynecology-obstetrics/delivery units, dialysis suites, and behavioral health units) that allow for a personalized approach, including glucose monitoring, insulin and/or noninsulin therapy, hypoglycemia management, diabetes self-management education, nutrition recommendations, and transitions of care.

How EndoTool Assists

• With both ETIV and ETSQ, A1C levels are just one of many factors integrated into the application to deliver patient specific dosing. When integrated with your hospital’s laboratory information system, EndoTool automatically incorporates A1C levels into the calculations, eliminating the need for manual data entry.
• EndoTool’s sophisticated computerized protocols are integrated into the electronic medical record for ease of workflow and can be utilized in all areas of the hospital. Insulin dosage is continually modified based on glycemic fluctuations as well as changes in carbohydrate intake.
• EndoTool assists in the management of hypoglycemia by recommending a precise dose of dextrose to return the blood glucose to a normal level without causing rebound hyperglycemia. It also can recommend a dose of dextrose to prevent impending hypoglycemia which is frequently caused by insulin stacking.

B. Glycemic Targets in Hospitalized Adults

Recommendations

• Insulin and/or other therapies should be initiated or intensified for treatment of persistent hyperglycemia starting at a threshold of ≥180 mg/dL (≥10.0 mmol/L) (confirmed on two occasions within 24 h) for noncritically ill (non-ICU) individuals.
• Once therapy is initiated, a glycemic goal of 140–180 mg/dL (7.8–10.0 mmol/L) is recommended for most critically ill (ICU) individuals with hyperglycemia.
• More stringent goals, such as 110–140 mg/dL (6.1–7.8 mmol/L) or 100–180 mg/dL (5.6–10.0 mmol/L), may be appropriate for selected patients and are acceptable if they can be achieved without significant hypoglycemia.

How EndoTool Assists

• EndoTool is configured to allow for up to three customized goal ranges per nursing unit. Regardless of which goal range is selected, the incidence of hypoglycemia is extremely low; less than 0.3% for blood glucoses <70mg/dl and 0.01% for blood glucoses < 40 mg/dl.
• It may be appropriate for some patients to have very stringent goals while others would benefit from the more conservative 140-180 goal range.

C. Glucose-Lowering Treatment in Hospitalized Patients

Recommendations

• Basal insulin or a basal plus bolus correction insulin regimen is the preferred treatment for noncritically ill hospitalized patients with poor oral intake or those who are taking nothing by mouth.
• An insulin regimen with basal, prandial, and correction components is the preferred treatment for most noncritically ill hospitalized patients with adequate nutritional intake.
• Use of a correction or supplemental insulin without basal insulin (often referred to as a sliding scale) in the inpatient setting is discouraged.

How EndoTool Assists

• To achieve these recommendations there is a need for multiple interventions by the healthcare team to manage the changing insulin requirements for a patient with inconsistent oral intake.
• EndoTool minimizes these interventions by allowing the selection of the most appropriate insulin dosing regimen. In the case of patients with poor oral intake, basal plus correction insulin can be ordered. If a patient’s intake improves, the application will also recommend prandial dosing without the need for the provider to modify the dosing regimen.
• Only basal, prandial and correction regimen is permitted in patients with Type 1 diabetes .
• Often insulin naïve patients with hyperglycemia are initially treated with correction insulin only. EndoTool recommends patients specific correction dosing through calculation of a specific insulin sensitivity factor as opposed to a standardized protocol. If the provider determines that the patient requires the addition of basal and prandial insulin, the dosing mode can be modified in EndoTool, and dosing will be adjusted based on the patient’s initial response to correction insulin.

D. Hypoglycemia

Recommendations

• A hypoglycemia management protocol should be adopted and implemented by each hospital or hospital system. A plan for preventing and treating hypoglycemia should be established for each individual. Episodes of hypoglycemia in the hospital should be documented in the medical record and tracked for quality improvement/quality assessment.
• Treatment regimens should be reviewed and changed as necessary to prevent further hypoglycemia when a blood glucose value of <70 mg/dL (3.9 mmol/L) is documented.

How EndoTool Assists

• EndoTool provides specific treatment recommendations for an episode of hypoglycemia. The dose of dextrose recommended is calculated to return the patient’s blood glucose to a pre-determined level (usually 130 mg/dl). The application will also recommend a dose of “prophylactic” carbohydrate to prevent what the application has calculated to be impending hypoglycemia.
• EndoTool analytics module allows the staff to track episodes of hypoglycemia in specific units or within specific time periods. The surveillance tool allows for monitoring of hypo and hyperglycemia on patients not yet treated with EndoTool.
• EndoTool continuously updates the insulin dosing regimen based on the patient’s response to the most recent dose of insulin.

Key Takeaways in Diabetes Care for Hospitalized Patients

Inpatient glycemic management encompasses numerous aspects that demand focused attention from healthcare professionals. However, the intricate nature of treating hospitalized patients with multiple comorbidities can lead to challenges in maintaining consistent care. EndoTool offers a solution by precisely and continuously adjusting insulin dosing, ensuring safe glycemic control. This not only enhances patient care but also significantly eases the workload of the healthcare team.

EndoTool Glucose Management System

When you choose EndoTool from Monarch Medical Technologies, you receive a true partner in inpatient glucose management. Our primary focus is to significantly reduce the workload and stress associated with glucose management. Our dedicated team, comprised of clinicians, project managers, trainers, and technical experts, ensures you are well equipped with the necessary tools and support for efficient and safe patient care. This approach not only enhances the quality of patient care but streamlines your teams’ operations, allowing them to focus on more patient-centric tasks. To see how EndoTool can support your institution, book a demonstration today.