“The wish for healing has ever been the half of health.”
–Seneca the Younger
Most people experience a stay in the hospital at least once in their lives, and for some, it is much more often than that. No matter what the reason for your admission to the hospital, it is imperative that your blood glucose levels be controlled while you are there.
More and more research shows that maintaining optimal blood glucose control in the hospital improves a person’s chances of having the best possible medical outcome. However, achieving optimal control in the hospital is a challenge. Stress tends to raise blood glucose level, and in the hospital, the stresses are many: Illness itself is a physical stress, as are pain, surgery, and other medical procedures such as having blood drawn for tests. Simply being in the hospital is a physical and mental stress with all of the changes in routine. And worrying about the reason you’re in the hospital, whether your diabetes is being controlled properly, how much the hospitalization is going to cost you, how your family or job is making out without you, etc., simply adds to it.
If your hospital admission is not an emergency, you and your health-care provider have more time to prepare so that some of the stress of being in the hospital can be minimized. For example, you can establish ahead of time whether your personal physician will be overseeing your care while you’re in the hospital or, if not, who will. You can also discuss how your diabetes will be controlled and whether and when to stop taking any medicines you may currently take. And you can make plans for dealing with such personal responsibilities as child care or pet care during your hospital stay.
If you are admitted to the hospital through the emergency room, it is standard practice for the hospital to try to notify your primary-care physician. If your primary-care physician has privileges to practice in that particular hospital, he may come to see you there. If not, you will be treated by a physician on the hospital staff. Once you are released, it’s a good idea to follow up with your personal physician and make him aware of your recent hospitalization.
Your hospital diabetes plan
Whether your hospital stay is a scheduled trip recommended by your health-care provider or the result of an illness or injury, treating your diabetes is an essential part of your hospital care. Components of that care should include the following:
- Your diagnosis of diabetes should be clearly noted in your medical record. When you speak with hospital staff members, double-check to make sure they are aware of your diabetes, including which type of diabetes you have, your current level of blood glucose control, and any diabetes-related complications you may have.
- Your care should include routine blood glucose monitoring by trained hospital personnel, with results noted in your hospital record and available to all members of the health-care team.
- Insulin doses given to cover your meals should be appropriately timed and adjusted according to the results of the blood glucose monitoring performed by hospital personnel.
- When necessary, supplemental, or “correction,” doses of insulin should be given along with your premeal insulin to lower high blood glucose levels.
- Your physician should monitor your need for correction doses and consider how often you typically need them when making adjustments to your overall hospital insulin regimen.
- If you receive any therapies that will likely worsen your blood glucose control, such as high-dose glucocorticoids (steroid-type drugs), adjustments to your insulin doses should be made based on your blood glucose levels.
- Typically, hospitals have guidelines for treating hypoglycemia (low blood glucose), which may be different from those you normally use to treat yourself. If you develop hypoglycemia during your hospital stay, you should be treated promptly, and the episode should be noted in your medical record.
- When you are admitted to the hospital, you should have an HbA1c test done unless the physician managing your diabetes care has access to a recent HbA1c test result. This will give the physician useful information about your current level of blood glucose control.
- A diabetes education plan that explains what you need to know when you go home should be made available to you. Your diabetes treatment plan after you are released from the hospital may be different from the one you were following before your visit to the hospital.
- You are admitted to the hospital to have surgery (particularly heart surgery).
- You are having an organ transplant.
- You have high blood glucose because you are taking a drug or drugs that cause high blood glucose, such as high-dose glucocorticoid (steroid) therapy.
- You have Type 1 diabetes and are taking in no food by mouth.
- Your heart is not pumping effectively (a condition called cardiogenic shock) and there is inadequate blood flow in your body.
- You are critically ill.
Controlling blood glucose in the hospital
Because not much is known about the use of diabetes drugs other than insulin in hospitalized patients, insulin is usually the drug of choice in the hospital, and other diabetes drugs are discontinued. (See “Diabetes Drugs in the Hospital” for more on this topic.)
The two methods of insulin delivery used in hospitals are continuous IV (intravenous) infusion, using a clear, short-acting insulin, and subcutaneous insulin — insulin given by injection under the skin or with an insulin pump — using a combination of long-acting and short-acting insulins or, in a pump, just short-acting insulin.
Intravenous insulin delivery is sometimes referred to as an “insulin drip.” An insulin drip is almost always used in the following situations:
Insulin drip therapy is also used to treat diabetic ketoacidosis and hyperosmolar hyperglycemic state, both of which are life-threatening complications of diabetes that occur as a result of prolonged high blood glucose levels coupled with inadequate insulin and dehydration. These conditions sometimes occur in people who are not aware that they have diabetes. In women with pre-existing diabetes who are pregnant, an insulin drip may be used to control blood glucose levels during labor and delivery.
Subcutaneous insulin therapy is more likely to be used in people are not critically ill. A variety of insulins may be used, depending on a person’s needs and why he is in the hospital. Typically, both basal insulin (“background” insulin that’s needed between meals and over-night) and mealtime insulin (insulin needed to cover food intake) are given. A person’s in-hospital insulin plan also typically includes instructions for supplemental, or “correction,” doses in the event of high blood glucose levels. Similarly, the insulin plan should include instructions for treating hypoglycemia.
The uncertainty of the daily routine in the hospital can make controlling blood glucose difficult. For example, the schedule for meals and insulin doses may be different from one day to the next because of tests or procedures that need to be done. However, if you are requiring correction doses or hypoglycemia treatments frequently, your physician will likely change your routine insulin dosing plan in an attempt to prevent frequent highs or lows.
Before you leave the hospital, make sure to ask how to maintain your blood glucose control once you’re home. If you already used insulin before coming to the hospital, your insulin needs may be higher than before if you were in the hospital for surgery, have been treated for an infection, or are now less active. They may be lower if you have lost weight or are eating less.
If you did not use insulin before your hospitalization, you may need to continue to take it — at least temporarily — to maintain your blood glucose levels in an optimal range when you go home. If so, you should be taught how to give an insulin injection before your discharge by a health-care professional who is knowledgeable in the use of insulin. Many hospitals have diabetes educators on staff who specialize in diabetes training. The diabetes educator can help you learn about your diabetes treatment plan and may also recommend that you return for additional training as an outpatient once you have recovered from your hospital stay.
Bedside blood glucose monitoring
Keeping track of your blood glucose levels while you are in the hospital is important to help the physicians and hospital staff be sure that your inpatient diabetes treatment plan is working (or make changes if it isn’t). The blood glucose monitoring that is done in the hospital is similar to the monitoring you do at home, except that a hospital meter is used, and someone else is lancing your finger and checking the blood. Just like at home, your results provide immediate information for timely decision making with regard to your diabetes treatment plan. Hospital staff will also perform regular testing of the meter itself to assure that it is sound and is giving accurate results. For this reason, hospitals prefer to use their own equipment for blood glucose monitoring, rather than the patient’s home meter. The hospital will have a system in place for recording the results of each blood glucose reading in your hospital record. (Click here to learn about blood glucose goals in the hospital.)
The timing of the blood glucose monitoring you receive in the hospital will usually be based on your individual needs. For patients who are eating, the usual recommendation is to monitor before each meal and at bedtime. For patients who are not eating, monitoring will likely occur every 4–6 hours to assess insulin needs. If your diabetes is being managed with an insulin drip, your blood glucose will typically be monitored hourly until it is stable, and then usually every two hours from then on.
Efforts to avoid hypoglycemia are an important part of the in-hospital diabetes management plan. Any reductions in food intake increase the risk for hypoglycemia if your insulin doses have not been adjusted to accommodate these changes. Another thing that could contribute to hypoglycemia is less-than-optimal timing of premeal insulin doses to match the timing of meals.
If hypoglycemia does occur, the hospital should have a treatment protocol to manage it. The treatment you receive is usually based on how low your blood glucose is. You may want to ask the hospital staff ahead of time how hypoglycemia is treated so you know what to expect should the need arise.
Nutrition in the hospital
Adequate nutrition is important for the healing process. While you are in the hospital, a food plan is usually determined and delivered by the hospital’s dietary service, which is staffed by registered dietitians and other nutrition professionals. Many hospitals use a “consistent carbohydrate” food plan for patients with diabetes, in which the patient makes food choices for each meal that add up to the recommended total carbohydrate grams per meal.
If you are scheduled for surgery, you may need to follow a “full liquid” or “clear liquid” diet in preparation. The liquids served in place of solid food will contain carbohydrate and will not be sugar-free.
It’s also possible that you will need an alternative form of feeding such as the use of a feeding tube (called enteral feeding) or intravenous feeding (called parenteral feeding). In these cases, your physician, in consultation with the hospital dietitian, will decide on the desired formulation of nutrients.
Before you leave the hospital, a registered dietitian who is familiar with the effect of food choices on blood glucose levels in people with diabetes will usually advise you on eating at home. The registered dietitian is responsible for integrating information about your condition, your eating and lifestyle habits, and your treatment goals to come up with a realistic, individualized meal plan for you. The registered dietitian may also recommend that you return as an outpatient for further nutrition counseling after you leave the hospital.
Being your own advocate
Nobody knows your diabetes better than you do. If your hospital stay is a planned one, speak to your physician and diabetes educator beforehand to find out the specifics of how your diabetes will be managed during your stay. Be sure and identify the physician who will be managing your diabetes, and make sure you understand the plan. (If you don’t, ask questions.)
In the event that you receive treatment in an emergency room or at an urgent care facility, it’s possible that you will know more about the latest technology for diabetes control than the people caring for you. Medical professionals who do not provide routine diabetes care, for example, may not be familiar with insulin pumps and how they work. If you use an insulin pump and are asked to remove it in one of these settings, you will need to communicate your urgent need for a physician’s order for an alternate method of insulin delivery to avoid developing high blood glucose.
Once admitted to the hospital, if you question any aspect of your inpatient diabetes treatment plan, ask for clarification. If you don’t feel able to speak up for yourself but do have a friend or family member who can do it for you, ask that person to speak with your caregivers in the hospital about your concerns.
With a physician’s order, a person with diabetes may be able to assist in managing his diabetes while in the hospital, as long as he is mentally competent and has a stable level of consciousness. A physician is also more likely to agree to self-management during the stay if a person has relatively stable insulin requirements and experience in managing his insulin doses and blood glucose monitoring at home. The patient and physician, in consultation with the hospital nursing staff, must agree that patient self-management is appropriate under the conditions of hospitalization and together must ensure that it is conducted according to hospital policy.
If you are managing your own diabetes in the hospital, all of your self-directed care should be reported to the nurse or other hospital staff member assigned to your care and documented by the staff member in your hospital record. Also, it is important to speak up if you don’t feel well enough to carry out your care or need assistance with your diabetes treatment plan at any time during your stay.
No matter what has put you in the hospital, diabetes management should always be a priority. Optimal blood glucose control during your stay may hasten your trip down the road to recovery.