Ensuring a Successful Hospital Stay

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In the past, it was considered acceptable for people with diabetes to have high blood glucose levels during a hospital stay. Fear of causing low blood glucose, or hypoglycemia, was a huge factor. But more recently, several studies have indicated that having high glucose during hospitalization can lead to poor health outcomes, including slow healing and infection. Further studies have demonstrated that good control reduces illness, can shorten the hospital stay, and even lowers the risk of death. This has prompted growing interest nationwide in improving diabetes management in the hospital setting, which is good news for people with diabetes.

Common reasons for hospitalization include a planned surgery, an illness, or the development of a diabetes complication. It is very important for people with diabetes who anticipate the need for a hospital stay to prepare for a successful visit. If you end up with an unexpected hospital stay, it will certainly challenge your best efforts to manage your diabetes, but hopefully the following information will help you be prepared for any such situation.

Preparing hospital staff for the stay
Make sure that the hospital staff is notified of your diabetes and your current level of glucose control, such as your most recent hemoglobin A1C level (a measure of glucose control over the previous 2–3 months). Report any wide fluctuations in glucose levels you may be experiencing or any previous experience with eithers lows or highs during hospitalization.

It is important that any surgeons, other doctors, and nurses who provide your care have knowledge of your current medication regimen, including specifics on insulin dosing. Be honest about how closely you stick to your prescribed medication regimen and diet: If you don’t consistently take your medicines or follow a particular meal plan at home, you could end up being overmedicated in the hospital and put at risk for a low.

Commonly asked questions
Below are some questions I frequently receive from people with diabetes regarding a hospital stay:

Why can’t I use my own diabetes medicines?
Hospitals require that people with diabetes use medicines provided by the hospital because it would be too difficult to ensure that medicines from an outside setting were stored properly. For instance, if medicines are kept in a pill reminder, it is difficult to identify them due to the widespread use of generics. To keep hospital costs down, the hospital cannot stock every medicine that a person may be taking, so it makes equivalent substitutes based on the medicines it does have.

Why can’t I monitor my blood glucose levels with my own meter while in the hospital?
Because the hospital meter undergoes strict controls each day to ensure it is accurate. However, you can ask to also check your blood sugar with your own meter at the same time to ensure that your home meter is accurate.

Why can’t my own personal physician care for me in the hospital?
Physicians with busy outpatient practices or those without hospital privileges are often unable to visit their patients during a hospital stay. Chances are that a hospitalist will provide your care. Hospitalists are physicians whose primary professional focus is the general medical care of people who are hospitalized. Most hospitalists are board-certified internists.

Why are my blood sugar levels well controlled at home but much higher during my hospital stay?
Many factors can contribute to variations in blood glucose levels during a hospitalization. The stress of illness, medicines such as steroids or other treatments, and the reason for which you are being hospitalized can all cause fluctuating blood glucose levels. The American Diabetes Association recommends keeping blood glucose levels below 180 mg/dl while in the hospital, but individual circumstances may vary. Hospitals are beginning to use a diabetes team made up of a physician, a nurse, a pharmacist, and a dietitian who focus on controlling blood sugar levels for hospitalized people with diabetes.

I take scheduled insulin at home but I was given a “sliding scale” insulin regimen during my hospital stay. Why is this?
Sliding-scale insulin regimens have historically been used in the hospital setting, but they are being phased out. A sliding scale treats high blood glucose by giving small doses of insulin when the blood glucose level is higher than 150 mg/dl. However, the risk of hypoglycemia with this type of regimen is of significant concern, since insulin is given without regard to whether the person has eaten.

Hospital guidelines now recommend the use of a structured insulin regimen, consisting of three components: “basal” insulin (long-acting insulin to provide coverage overnight and between meals), “nutritional” or “premeal” insulin (short-acting insulin to cover the blood glucose rise from meals), and “correctional” or “supplemental” insulin, which allows for adjustment of the scheduled insulin. A person’s total daily dose of insulin is the sum of all of these, and represents the amount of insulin that he requires over the course of one day while receiving adequate nutrition.

According to this report, “It is important to note that when a person with diabetes is acutely ill or stressed, as is commonly the case in the hospital setting, total daily insulin requirements increase. This is due to the action of counterregulatory hormones, such as catecholamines, cortisol, growth hormone, and glucagon. A person who is hospitalized is therefore likely to need more insulin than he requires when healthy.”

Regimens combining the components listed above have been shown to reduce fluctuations in glucose levels and reduce the number of days a person with diabetes is hospitalized. If you are on scheduled insulin at home but are experiencing fluctuating blood glucose levels due to the sliding scale use in the hospital, ask if your home regimen can be resumed. Also ask whether there is a diabetes team or specialist available to help manage your diabetes while in the hospital.

If I use an insulin pump, will I be allowed to use it during my hospital stay?
That depends on whether or not the hospital has a policy in place for the use of insulin pumps. Unfortunately, hospital staff are typically not familiar with the technology of insulin pumps. Also, most hospitals do not carry the necessary supplies for insulin pump use. If your cognitive ability is affected by illness or by medicines (such as those used for pain relief), you may not be able to perform the necessary tasks associated with pump use. Therefore, you may be switched to an injection regimen. In preparation for this scenario, you should write down the following information from your pump settings: Total 24-hour basal amount, insulin sensitivity factor, and insulin-to-carbohydrate ratio. This will help the hospital clinician convert your pump settings to a temporary insulin injection regimen.

I am taking oral medicine for my diabetes. Why was I given insulin during my hospital stay?
Many oral medicines are long lasting, which can place you at risk for having low blood glucose if you are not allowed to eat for prolonged periods of time for medical tests. Also, many oral medicines may interact with other commonly used hospital medicines, which can result in low blood glucose. Insulin is a safe alternative.

Keeping yourself safe during a hospital stay
Speaking up for yourself in the hospital setting is very important. Don’t hesitate to ask questions and come prepared with a list of your current medicines for diabetes, most recent A1C result, and a recent blood glucose log from home.

If you are prone to hypoglycemia, ask to keep glucose tablets close by in case your meal is late. Make sure you report any symptoms of low blood glucose right away to your nurse. If your meal comes late, or if it doesn’t arrive, call your nurse.

Make sure your nurse and physician are told if you are nauseous or have vomited. If meals or medicines don’t stay down, the hospital staff will need to take other measures to control your glucose levels.

Find out how much fasting will be required before any procedures, as well as what plans are in place to ensure your blood glucose remains within a safe range during these times.

Also ask how long after surgery or treatment it will be before you can resume a normal eating plan, as well as what provisions will be made to control your blood sugar levels after an operation.

Recovering from a hospital stay
Once you return home, careful monitoring of your blood glucose levels remains very important. Depending on your condition, it may be helpful to have a friend or relative help with meals, medicines, and monitoring. Any friends or family who are assisting you with your diabetes should stay in contact your provider until you are able to handle this personally. Check-ins from members of your diabetes care team can be useful as well. Before you are discharged from the hospital, make sure the hospital staff provides you with details about when and how you should return to your regular diabetes care regimen if changes were made during your stay.

A hospital stay is stressful, but good preparation can help you recover as quickly as possible. In the words of health writer Craig Stoltz, “Be assertive, be clear, and be sure to have family, friends, or your diabetes care team there to advocate for you.”

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