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Diabetic Ketoacidosis and\nHyperglycemic Hyperosmolar State\nThere is considerable variability in the\npresentation of DKA and HHS, ranging\nfrom euglycemia or mild hyperglycemia | [
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from euglycemia or mild hyperglycemia\nand acidosis to severe hyperglycemia,diabetesjournals.org/care Diabetes Care in the Hospital S301\n©AmericanDiabetesAssociation | [
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dehydration, and coma; therefore, indi-\nvidualization of treatment based on acareful clinical and laboratory assess-ment is needed (75,140 –142).\nManagement goals include restoration | [
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of circulatory volume and tissue perfusion,resolution of ketoacidosis, and correctionof electrolyte imbalance and acidosis. It isalso essential to treat any correctable un-derlying cause of DKA, such as sepsis, myo-cardial infarction, or stroke. In | [
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and mentally obtunded individuals with\nDKA or HHS, continuous intravenous insu-lin is the standard of care. Successful transi-tion from intravenous to subcutaneousinsulin requires administration of basal in-sulin 2 –4 h before the intravenous insu- | [
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lin is stopped to prevent recurrence ofketoacidosis and rebound hyperglyce-mia (72,73,140). Recent studies havereported that the administration of alow dose of basal insulin analog in addi-\ntion to intravenous insulin infusion may | [
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] |
tion to intravenous insulin infusion may\nprevent rebound hyperglycemia without in-creased risk of hypoglycemia (74 –76,140).\nThere is no signifi cant difference in out- | [
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] |
There is no signifi cant difference in out-\ncomes for intravenous human regularinsulin versus subcutaneous rapid-actinganalogs when combined with aggressivefluid management for treating mild or | [
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moderate DKA (143). Individuals withuncomplicated DKA may sometimes betreated with subcutaneous rapid-acting\ninsulin analogs in the emergency depart- | [
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ment or step-down units (144). This ap-proach may be safer and more cost-effective than treatment with intravenousinsulin. If subcutaneous insulin adminis-tration is used, it is important to providean adequate fluid replacement, frequent | [
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POC blood glucose monitoring, treatmentof any concurrent infections, and appro-priate follow-up to avoid recurrent DKA.Several studies have shown that the useof bicarbonate in people with DKA\nmade no difference in the resolution | [
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made no difference in the resolution\nof acidosis or time to discharge, and itsuse is generally not recommended(145). For further treatment information,refer to recent in-depth reviews (53,107,146).\nTRANSITION FROM THE HOSPITAL\nTO THE AMBULATORY SETTING | [
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] |
TO THE AMBULATORY SETTING\nRecommendation\n16.14 A structured discharge plan\nshould be tailored to the individual\nwith diabetes. BA structured discharge plan tailored to\nthe individual may reduce the length of | [
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the individual may reduce the length of\nhospital stay and readmission rates andincrease satisfaction with the hospital ex-perience (147). Multiple strategies arekey, including diabetes self-management\neducation prior to discharge, diabetes | [
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medication reconciliation with attentionto access, and scheduled virtual and/orface-to-face follow-up visits after discharge.Discharge planning should begin at admis-sion and be updated as individual needschange (148,149). | [
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The transition from the acute care set- | [
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ting presents risks for all people with dia-betes. Individuals may be discharged tovaried settings, including home (with orwithout visiting nurse services), assistedliving, rehabilitation, or skilled nursing fa-cilities. For individuals discharged to home | [
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or assisted living, the optimal discharge\nplan will need to consider diabetes typeand severity, effects of the illness on bloodglucose levels, and the individual ’sc i r -\ncumstances, capabilities, and preferen-ces (21,150,151). See Section 13, “Older | [
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Adults, ”for more information.\nAn outpatient follow-up visit with the | [
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primary care clinician, endocrinologist, ordiabetes care and education specialistwithin 1 month of discharge is advised forall individuals experiencing hyperglycemiaand/or hypoglycemia in the hospital. If gly-cemic medications are changed or glucose | [
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] |
management is not optimal at discharge,\nan earlier appointment (in 1 –2 weeks) is | [
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an earlier appointment (in 1 –2 weeks) is\npreferred, and frequent contact may beneeded to avoid hyperglycemia and hypo-glycemia. A discharge algorithm for gly-cemic medication adjustment, based onadmission A1C, diabetes medications be- | [
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] |
fore admission, and insulin usage during\nhospitalization was found useful to guidetreatment decisions and signi ficantly im-\nprove A1C after discharge (4).\nClear communication with outpatient | [
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] |
Clear communication with outpatient\nhealth care professionals directly or viahospital discharge summaries facilitates\nsafe transitions to outpatient care. Provid- | [
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ing information regarding the root causeof hyperglycemia (or the plan for determin-ing the cause), related complications andcomorbidities, and recommended treat-ments can assist outpatient health careprofessionals as they assume ongoing care. | [
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] |
The Agency for Healthcare Research\nand Quality recommends that, at a min-imum, discharge plans include the fol-lowing (152):Medication Reconciliation | [
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\x81Home and hospital medications mustbe cross-checked to ensure that nochronic medications are stopped andto ensure the safety of new and oldprescriptions.\n\x81Prescriptions for new or changed medi-cation should be filled and reviewed | [
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with the individual and care partners ator before discharge.\nStructured Discharge\nCommunication\n\x81I n f o r m a t i o no nm e d i c a t i o nc h a n g e s , | [
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pending tests and studies, and follow-upneeds must be accurately and promptlycommunicated to outpatient health careprofessionals.\n\x81Discharge summaries should be trans-mitted to the primary care clinician assoon as possible after discharge. | [
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\x81Scheduling follow-up appointmentsprior to discharge with people with dia-betes agreeing to the time and placeincreases the likelihood that they willattend. | [
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] |
It is recommended that the followingareas of knowledge be reviewed and ad-dressed before hospital discharge:\n\x81Identi fication of the health care profes-\nsionals who will provide diabetes care\nafter discharge. | [
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after discharge.\n\x81Level of understanding related to thediabetes diagnosis, glucose monitoring,home glucose goals, and when to call ahealth care professional.\n\x81Definition, recognition, treatment, and\nprevention of hyperglycemia andhypoglycemia. | [
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\x81When and how to take blood glu-cose-lowering medications, includinginsulin administration and noninsulininjectables.\n\x81Sick-day management (21,151).\n\x81Proper use and disposal of diabetessupplies, e.g., insulin pen, pen needles,syringes, and lancets. | [
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People with diabetes must be pro-\nvided with appropriate durable medicalequipment, medications, supplies (e.g.,blood glucose test strips or CGMS302 Diabetes Care in the Hospital Diabetes Care Volume 47, Supplement 1, January 2024 | [
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sensors), prescriptions, and appropriate\neducation at the time of discharge to\navoid a potentially dangerous hiatus in\ncare.\nPREVENTING ADMISSIONS AND\nREADMISSIONS\nIn people with diabetes, the hospital read-\nmission rate is between 14% and 20%, | [
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mission rate is between 14% and 20%,\nwhich is nearly twice that in people with-\nout diabetes (148,153). This may result inincreased diabetes distress and has signi fi-\ncantfinancial implications. Of people with\ndiabetes who are hospitalized, 30% have | [
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diabetes who are hospitalized, 30% have\ntwo or more hospital stays, and these ad-\nmissions account for over 50% of hospitalcosts for diabetes (154). Factors contribut-\ning to readmission include male sex, | [
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ing to readmission include male sex,\nlonger duration of prior hospitalization,number of previous hospitalizations, num-\nber and severity of comorbidities, and\nlower socioeconomic and/or educationalstatus; factors that may reduce readmis- | [
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sion rates include scheduled home health\nvisits and timely ambulatory follow-up\ncare (148,153). While there is no standard\nto prevent readmissions, several successfulstrategies have been reported that identify\nhigh-risk individuals and offer some possi- | [
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high-risk individuals and offer some possi-\nble solutions (148). These include reachingout to people with ketosis-prone diabetes\n(155), insulin treatment of individuals with\nadmission A1C >9% (>75 mmol/mol) | [
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] |
admission A1C >9% (>75 mmol/mol)\n(156), and the use of a transitional caremodel (157). For people with diabetickidney disease, collaborative person-\ncentered medical homes may decrease\nrisk-adjusted readmission rates (158). | [
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] |
risk-adjusted readmission rates (158).\nA g ei sa l s oa ni m p o r t a n tr i s kf a c t o ri n\nhospitalization and readmission among\npeople with diabetes (refer to Section 13,\n“Older Adults, ”for detailed criteria). Suc- | [
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] |
“Older Adults, ”for detailed criteria). Suc-\ncessful proactive care transitions from in-\npatient to outpatient is a key strategy for\npreventing readmission.\nReferences\n1 . S e i s aM O ,S a a d iS ,N a y f e hT ,e ta l .As y s t e m a t i c | [
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review supporting the Endocrine Society clinical\npractice guideline for the management of\nhyperglycemia in adults hospitalized for noncritical\nillness or undergoing elective surgical procedures. J\nClin Endocrinol Metab 2022;107:2139– 2147 | [
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Clin Endocrinol Metab 2022;107:2139– 2147\n2. ElSayed NA, Aleppo G, Aroda VR, et al.\nAmerican Diabetes Association. 16. Diabetes care\nin the hospital: S t a n d a r d so fC a r ei nD i a b e t e s —\n2023 . Diabetes Care 2023;46(Suppl. 1):S267 –S278 | [
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] |
2023 . Diabetes Care 2023;46(Suppl. 1):S267 –S278\n3. Pasquel FJ, Gomez-Huelgas R, Anzola I, et al.\nPredictive value of admission hemoglobin A1c on\ninpatient glycemic control and response to insulin\ntherapy in medicine and surgery patients with type 2 | [
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] |
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5. Carpenter DL, Gregg SR, Xu K, Buchman TG,Coopersmith CM. Prevalence and impact ofunknown diabetes in the ICU. Crit Care Med2015;43:e541– e550\n6. Nanayakkara N, Nguyen H, Churilov L, et al.Inpatient HbA1c testing: a prospective observational | [
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study. BMJ Open Diabetes Res Care 2015;3:e000113\n7. Nassar CM, Montero A, Magee MF. Inpatient\ndiabetes education in the real world: an overviewof guidelines and delivery models. Curr Diab Rep2019;19:103\n8. Garg R, Schuman B, Bader A, et al. Effect of | [
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Errors. Aspden P, Wolcott J, Bootman JL,\nCronenwett LR, Eds. Washington, DC, NationalAcademies Press, 2007\n13. Sly B, Russell AW , Sullivan C. Digital inter-\nventions to improve safety and quality of | [
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ventions to improve safety and quality of\ninpatient diabetes management: a systematicreview. Int J Med Inform 2022;157:104596\n14. Nguyen M, Jankovic I, Kalesinskas L, Baiocchi | [
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14. Nguyen M, Jankovic I, Kalesinskas L, Baiocchi\nM, Chen JH. Machine learning for initial insulinestimation in hospitalized patients. J Am MedInform Assoc 2021;28:2212– 2219 | [
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1 5 . A k i b o y eF ,S i h r eH K ,A lM u l h e mM ,R a y m a nG, Nirantharakumar K, Adderley NJ. Impact of\ndiabetes specialist nurses on inpatient care: a\nsystematic review. Diabet Med 2021;38:e14573\n16. Wang YJ, Seggelke S, Hawkins RM, et al. | [
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16. Wang YJ, Seggelke S, Hawkins RM, et al.\nImpact of glucose management team on outcomesof hospitalizaron in patients with type 2 diabetesadmitted to the medical service. Endocr Pract2016;22:1401– 1405 | [
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20. Magee MF, Baker KM, Bardsley JK, WesleyD, Smith KM. Diabetes to go-inpatient: pragmaticlessons learned from implementation of technology-enabled diabetes survival skills education within\nnursing unit workfl ow in an urban, tertiary care | [
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nursing unit workfl ow in an urban, tertiary care\nhospital. Jt Comm J Qual Patient Saf 2021;47:\n107– 119\n21. Pinkhasova D, Swami JB, Patel N, et al.\nPatient understanding of discharge instructionsfor home diabetes self-management and risk for | [
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visits. Endocr Pract 2021;27:561– 566\n22. Society of Hospital Medicine. Glycemiccontrol for hospitalists. Accessed 21 August 2023.Available from https://www.hospitalmedicine.org/clinical-topics/glycemic-control/\n23. Arnold P, Scheurer D, Dake AW, et al. | [
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23. Arnold P, Scheurer D, Dake AW, et al.\nHospital guidelines for diabetes management\nand the Joint Commission-American DiabetesAssociation Inpatient Diabetes Certi fication. Am J\nMed Sci 2016;351:333– 341 | [
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Med Sci 2016;351:333– 341\n24. Association of British Diabetologists. JointBritish Diabetes Societies (JBDS) for Inpatient\nCare Group. Accessed 21 August 2023. Available\nfrom https://abcd.care/jbds-ip\n25. Agiostratidou G, Anhalt H, Ball D, et al. | [
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25. Agiostratidou G, Anhalt H, Ball D, et al.\nStandardizing clinically meaningful outcomemeasures beyond HbA\n1cfor type 1 diabetes: a\nconsensus report of the American Association ofClinical Endocrinologists, the American Association | [
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of Diabetes Educators, the American Diabetes\nAssociation, the Endocrine Society, JDRF International,The Leona M. and Harry B. Helmsley Charitable Trust,the Pediatric Endocrine Society, and the T1DExchange. Diabetes Care 2017;40:1622– 1630 | [
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26. Cardona S, Gomez PC, Vellanki P , et al.\nClinical characteristics and outcomes of\nsymptomatic and asymptomatic hypoglycemiain hospitalized patients with diabetes. BMJOpen Diabetes Res Care 2018;6:e000607\n27. Van den Berghe G, Wouters P , Weekers F, | [
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27. Van den Berghe G, Wouters P , Weekers F,\net al. Intensive insulin therapy in critically ill\npatients. N Engl J Med 2001;345:1359– 1367\n28. Finfer S, Chittock DR, Su SY , et al.; NICE- | [
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2011;154:268– 282\n30. Sathya B, Davis R, Taveira T, Whitlatch H, WuWC. Intensity of peri-operative glycemic controland postoperative outcomes in patients withdiabetes: a meta-analysis. Diabetes Res Clin Pract\n2013;102:8 –15 | [
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2013;102:8 –15\n31. Umpierrez G, Cardona S, Pasquel F, et al.\nRandomized controlled trial of intensive versusconservative glucose control in patients undergoingcoronary artery bypass graft surgery: GLUCO-CABGtrial. Diabetes Care 2015;38:1665 –1672 | [
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32. Furnary AP , Wu Y , Bookin SO. Effect of\nhyperglycemia and continuous intravenous insulin\ninfusions on outcomes of cardiac surgical procedures:the Portland Diabetic Project. Endocr Pract 2004;10(Suppl. 2):21 –33 | [
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33. Magaji V, Nayak S, Donihi AC, et al.Comparison of insulin infusion protocols targeting110-140 mg/dL in patients after cardiac surgery.\nDiabetes Technol Ther 2012;14:1013 –1017\n34. Flory JH, Aleman JO, Furst J, Seley JJ. Basal | [
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34. Flory JH, Aleman JO, Furst J, Seley JJ. Basal\ninsulin use in the non-critical care setting: isfasting hypoglycemia inevitable or preventable? JDiabetes Sci Technol 2014;8:427– 428diabetesjournals.org/care Diabetes Care in the Hospital S303 | [
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17. Diabetes Advocacy: Standards\nof Care in Diabetes— 2024\nDiabetes Care 2024;47(Suppl. 1):S307 –S308 |https://doi.org/10.2337/dc24-S017American Diabetes Association\nProfessional Practice Committee * | [
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] |
Professional Practice Committee *\nThe American Diabetes Association (ADA) “Standards of Care in Diabetes ”includes\nthe ADA ’s current clinical practice recommendations and is intended to provide the | [
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evaluate quality of care. Members of the ADA Professional Practice Committee, aninterprofessional expert committee, are responsible for updating the Standards ofCare annually, or more frequently as warranted. For a detailed description of ADA | [
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standards, statements, and reports, as well as the evidence-grading system for ADA ’s\nclinical practice recommendations and a full list of Professional Practice Committee | [
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members, please refer to Introduction and Methodology. Readers who wish to com-ment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.\nManaging the daily health demands of diabetes can be challenging. People living | [
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with diabetes should not have to face discrimination due to diabetes. By advocatingfor the rights of those with diabetes at all levels, the American Diabetes Association(ADA) can help to ensure that they live a healthy and productive life. A strategic | [
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live a healthy and productive life. A strategic goalof the ADA is for more children and adults with diabetes to live free from the burdenof discrimination. The ADA is also focused on making sure cost is not a barrier to suc-cessful diabetes management. | [
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One tactic for achieving these goals has been to implement the ADA Standards of | [
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] |
Care through advocacy-oriented position statements. The ADA publishes evidence-based, peer-reviewed statements on topics such as diabetes and employment, diabe-tes and driving, insulin access and affordability, and diabetes management in certainsettings | [
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and diabetes management in certainsettings such as schools, childcare programs, and detention facilities. In addition to theADA’ s clinical documents, these advocacy statements are important tools in educating | [
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schools, employers, licensing agencies, policy makers, and others about the intersec-tion of diabetes management and the law and for providing scienti fically supported\npolicy recommendations.\nADVOCACY STATEMENTS | [
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policy recommendations.\nADVOCACY STATEMENTS\nThe following is a partial list of advocacy statements ordered by publication date, withthe most recent statement appearing first. A comprehensive list of advocacy state- | [
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ments is available at professional.diabetes.org/content/key-statements-and-reports.\nCare of Young Children With Diabetes in the Childcare and Community\nSetting\nVery young children (aged <5 years) with diabetes have legal protections and can be | [
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safely cared for by childcare professionals with appropriate training, access to resour-\nces, and a communication system with parents/guardians and the child ’sd i a b e t e s | [
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health care professional. Refer to the published ADA advocacy statement for infor-mation on young children aged <5 years in settings such as childcare centers, pre-\nschools, camps, and other programs (1).*A complete list of members of the American | [
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Diabetes Association Professional Practice Committeecan be found at https://doi.org/10.2337/dc24-SINT.\nDuality of interest information for each author is\navailable at https://doi.org/10.2337/dc24-SDIS.\nSuggested citation: American Diabetes Association | [
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] |
Suggested citation: American Diabetes Association\nProfessional Practice Committee. 17. Diabetesadvocacy: Standards of Care in Diabetes —2024.\nDiabetes Care 2024;47(Suppl. 1):S307– S308 | [
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