Optimizing Care of the Inpatient with Hyperglycemia and Diabetes: Case Studies in Action

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1 Optimizing Care of the Inpatient with Hyperglycemia and Diabetes: Case Studies in Action Learning Objectives Identify patient situations where specific attention to glycemic control is warranted Determine whether patients in specific situations are at greater or lesser risk of hyperglycemia and/or hypoglycemia Describe specific situations where glucose control is particularly challenging 2 1

2 Case Studies Available Insulin needs in patients on high dose steroids Insulin needs and nutrition (enteral, total parenteral) Insulin needs in patients undergoing surgery Transition to outpatient status Use of insulin pumps in the hospital Inpatient Hyperglycemia and Poor Outcomes in Numerous Settings Study Pidala et al, 2011 Patient Population Steroid use in transplant patients Significant Hyperglycemia-Related Outcomes Mortality risk Sarkisian et al, 2009 Total parenteral nutrition Mortality risk, ARF Pasquel et al, 2010 Total parenteral nutrition Mortality risk, pneumonia risk Frisch et al, 2009 Noncardiac surgery Mortality risk, surgery-specific risk Pidala J et al. Biol Blood Marrow Transplant. 2011;17: ; Sarkisian S et al. Can J Gastroenterol. 2010;24: Pasquel FJ, et al. Diabetes Care. 2010;33: ; Frisch A, et al. Diabetes. 2009;58(suppl 1):101-OR. 4 2

3 Current Recommendations for Hospitalized Patients All critically ill patients in intensive care unit settings BG level mg/dl Intravenous insulin preferred Non critically ill patients Random: <180 mg/dl Pre-meal: <140 mg/dl Scheduled SC insulin preferred Sliding-scale insulin discouraged Hypoglycemia Reassess the regimen if BG level is <100 mg/dl Modify the regimen if BG level is <70 mg/dl AACE and ADA Consensus Statement on Inpatient Statement on Inpatient Glycemic Control. Endocr Pract. 2009;15: Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Setting: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab,.2012;97: Case Study: Steroids 78-year-old woman is hospitalized for worsening dyspnea and cough She has had chronic obstructive pulmonary disease (COPD) since age 55 No prior history of diabetes 6 3

4 Case Study: Steroids Medications Fluticasone propionate 2 puffs twice a day Albuterol inhaler, 2 puffs as needed Amlodipine 5 mg 1 daily, Lisinopril 10mg 1 daily (HTN) Simvastatin 20 mg 1 daily (Cholesterol) 7 Case Study: Steroids Examination Mild respiratory distress Afebrile O2 sat: 91% on room air Diffuse pulmonary wheezes Normal heart sounds No edema 8 4

5 Case Study: Steroids Laboratory Values WBC: 12.5 Lytes normal; BUN: 12/ SCr: 0.9 ABG: ph 7.45, PCO2 32, P02 64 Random glucose: 150 mg/dl A1C : 6.2% 9 Case Study: Steroids Patient admitted and started on Solumedrol 40 mg IV q 6 hrs BG on day 2 climbs to 210 mg/dl 10 5

6 What is your assessment of this patient s glycemic status? 1. New onset diabetes 2. Steroid-induced hyperglycemia 3. Stress-induced hyperglycemia (disease-related) 11 Frequency of Hyperglycemia in Patients Receiving High-dose Corticosteroids All Pa ents Percent 70 No Documented History of Diabetes History of Diabetes > 2 BG > 200 mg/dl Episodes > 1 BG > 200 mg/dl High-dose defined as a dose equivalent of at least 40 mg per day of prednisone. Donihi AC, et al. Endocr Pract. 2006;12(4):

7 Hyperglycemia and Steroids Common complication of glucocorticoid therapy prevalence 20-50% among patients without a prior DM history Results from Increases in hepatic glucose production Impairment of glucose uptake in peripheral tissues, All of this contributes to increases in postprandial glucose Predictors: Total glucocorticoid dose Duration of glucocorticoid therapy Increasing age Umpierrrez G et al. J Clin Endocrinol Metab Jan;97(1): Clore JN, et al. Endocr Pract. 2009;15(5): How would you treat this patient? 1. Sliding scale insulin 2. Standard basal bolus insulin therapy 3. Basal bolus therapy with emphasis on postprandial glucose levels 4. Intravenous insulin therapy 5. No glucose lowering therapy required 14 7

8 General Recommendations: Hyperglycemia Associated with Steroids Discontinue OADs Initiate sc basal bolus insulin therapy is recommended Starting insulin dose and timing of insulin administration individualized depending on severity of hyperglycemia and duration and dosage of steroid therapy. Suggested starting dosage of 0.3 to 0.5 U /kg d For patients receiving high-dose glucocorticoids and in those with severe hyperglycemia that is difficult to control, the use of continuous insulin infusion may be appropriate Umpierrrez G et al. J Clin Endocrinol Metab Jan;97(1): Moghissi ES, et al. Endocr Pract. 2009;15: Basal Bolus Therapy with Emphasis on Nutritional Insulin Medium-dose glucocorticoids (40 60 mg/d) tend to cause minimal increase in FPG and marked elevation in PPG Scheduled Basal Nutritional* Insulin drip NPH Long-acting insulin analog (glargine, detemir) Emphasis on regular or rapid-acting insulin analog Supplemental/ Correction* Regular or rapidacting insulin analog q4 6h Analog Mixes Clement S, et al. Diabetes Care. 2004;27: Moghissi ES, et al. Endocr Pract. 2009;15: * Rapid analog preferred 16 8

9 Hyperglycemia and Glucocorticoid Therapy: Summary Institute glucose monitoring for at least 48 hours in all patients Prescribe insulin therapy as needed according to results of bedside BG monitoring During initiation and taper of steroid therapy, proactive adjustment of insulin therapy can help avoid uncontrolled hyperglycemia and hypoglycemia Umpierrrez G et al. J Clin Endocrinol Metab Jan;97(1): Moghissi ES, et al. Endocr Pract. 2009;15: Insulin needs and nutrition (enteral, total parenteral) 9

10 Case Study: Nutrition 55-year old obese male is admitted hemorrhagic pancreatitis, no prior history of diabetes On admission, his BG 200 mg/dl A1C 7.5% (previously unrecognized DM) Patient is not eating, and it is anticipated that he will not be able to eat for one week Total parenteral nutrition is started 19 Hyperglycemia During TPN: Marker of Poor Outcomes & Mortality in the Hospital Admission p = p = p = p = < > < > < > > Blood Glucose (mg/dl) Pasquel et al. Diabetes Care. 2010;33:

11 TPN, Glucose and Patient Mortality Study Hyperglycemia definition (mg/dl) Mortality Odds Ratio Cheung (2005) > Lin (2007) > Sarkisian (2009) Pasquel (2010) > Olveira (2012) > Case Study: Total Parenteral Nutrition What is the insulin treatment would you recommend for a DM patient on TPN? 1. IV insulin, separate from TPN 2. Insulin added to TPN 3. Basal bolus insulin 22 11

12 General Recommendations: Hyperglycemia Associated with Parenteral Nutrition (PN) For patients receiving PN, regular insulin administered as part of the PN formulation can be both safe and effective Subcutaneous correction-dose insulin is often used, in addition to insulin that is mixed with the nutrition When starting PN, the initial use of a separate insulin infusion can help in estimating the total daily dose of insulin that will be required. Separate IV insulin infusions may be needed to treat marked hyperglycemia during PN Umpierrrez G et al. J Clin Endocrinol Metab Jan;97(1): Moghissi ES, et al. Endocr Pract. 2009;15: Case Study: Insulin needs and nutrition 70 year old woman admitted with a stroke She has a prior history of T2DM, controlled on oral agents BG on admission 150 mg/dl, A1C 7% She is currently unable to swallow Continuous enteral nutrition is started on hospital day

13 Case Study: Insulin needs and nutrition What is insulin treatment would you recommend for a DM patient on enteral tube feedings? (BG 150 to 300 mg/dl) 1. Sliding scale only with rapid-acting insulin? 2. IV insulin variable rate infusion? 3. NPH or premixed analog 70/30 every 8 hours? 4. Basal insulin every 12 hours? 5. Regular insulin every 6 hours? 25 Complications of Enteral Nutrition A prospective and observational study carried out in 64 patients average age (mean age 76.2 y) receiving EN on an Internal Medicine Inpatient Unit Percent of patients Most frequent complications: Should blood glucose levels be checked in patients receiving enteral nutrition? Pancorbo Hidalgo PL. J Clin Nsa. 2001;10:

14 Glycemic Management of the Patient Receiving Enteral Nutrition Continuous enteral nutrition (EN) Basal: 40-50% of TDD as long or intermediate acting insulin given once twice a day Short acting 50-60% of TDD given q6h Cycled enteral nutrition Intermediate acting insulin given together with a rapid or short acting insulin with start of TF Rapid or short acting insulin administered q4 to 6 hours for duration of EN administration Correctional insulin given for BG above goal range Bolus enteral nutrition Rapid acting or short acting insulin given prior to each bolus Umpierrez et al, Endocrine Society Non-ICU Guideline. J Clin Endocrinol Metab Jan;97(1): Blood Glucose Monitoring In previously normoglycemic patients receiving therapies associated with hyperglycemia, such as corticosteroids, enteral nutrition (EN ), & parenteral nutrition (PN) Bedside point of care (POC) testing is recommended for at least 24 to 48 h after starting these therapies Those with BG measures > 140 mg/dl require ongoing POC testing with appropriate therapeutic intervention Frequent glucose monitoring is indicated in patients treated with medication change that could alter glycemic control, e.g. corticosteroid use or abrupt discontinuation of EN or PN Are patients receiving high-dose steroid therapy having BG levels checked in your institution? Umpierrrez G et al. J Clin Endocrinol Metab Jan;97(1):

15 Insulin needs in patients undergoing surgery Case Study: Surgery 60 year old woman with T2DM treated with insulin is admitted for hip fracture Her outpatient insulin regimen is as follows Premixed analog 70/30, 30 units twice a day Admission glucose = 180 mg/dl 30 15

16 How would you treat this patient? 1. Sliding scale insulin 2. Standard basal bolus insulin therapy 3. Basal bolus therapy with emphasis on postprandial glucose levels 4. Intravenous insulin therapy 5. No glucose lowering therapy required 31 Physiologic Components of Insulin Therapy Basal insulin: detemir (Levemir ), glargine (Lantus ), NPH (Humulin N, Novolin N) The amount of insulin necessary to regulate glucose levels between meals and overnight Nutritional insulin: aspart (NovoLog ), glulisine (Apidra ), lispro (HumaLog ), regular (Humulin R, Novolin R) The amount of insulin required to cover meals, IV dextrose, enteral nutrition, TPN or other nutritional supplements Correctional insulin: (Supplemental insulin) Refers to supplemental doses of rapid or short acting insulin given to correct elevations in blood glucose that occur despite use of basal and nutritional insulin Usually administered before meals together with prandial insulin IV, intravenous; TPN, total parenteral nutrition 32 16

17 Basal-Bolus Superior to Sliding Scale Insulin Treatment for Inpatient Hyperglycemia Mean BG (mg/dl) * 200 * * Basal-bolus SSI Admit Days of Therapy No differences in the rate of hypoglycemia or hospital LOS. <.01; <.05. Error bars denote standard deviation. Insulin glargine + glulisine: 0.4 units/kg for BG mg/dl; 0.5 units/kg for BG mg/dl (1/2 daily dose given as basal insulin). SSI = regular insulin 4 times daily for BG > 140 mg/dl. *P P Umpierrez GE, et al. Diabetes Care. 2007;30: Basal Bolus vs Sliding Scale in the RABBIT 2 Surgery Study Outcomes and Hypoglycemia Achievement of Glucose Goals Percent of Pa ents with BG <140 mg/dl 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Hospital Complications* BG <70 mg/dl BG <40 mg/dl Basal Bolus 8.6% 23.1% 3.8% Sliding Scale 24.3% 4.7% 0% P value < P < % 31% Scheduled Basal Bolus Sliding Scale * Composite of postoperative complications including wound infection, pneumonia, bacteremia, and respiratory and acute renal failure. Umpierrez GE, et al. Diabetes Care Feb;34:

18 Case Study A 48-year-old woman is ready to eat 36 hours after coronary artery bypass graft surgery Between 1 AM and 7 AM, she was receiving an average of 2 units of intravenous regular insulin per hour, with a glucose level of mg/dl She was given a small amount of juice at 7 AM, and her glucose level increased to 195 mg/dl, prompting an increase in the infusion rate to 3 U/h 35 How would you convert her 30 units of premixed insulin twice a day to basal bolus insulin? Total daily dose = 60 units; give half as basal (30 units long-acting basal analog at bedtime, 30 units as mealtime insulin divided at each meal [10 units rapidacting analog three times daily when food served) 36 18

19 How would you estimate basal bolus insulin dosing if prior insulin dose informatin was not available? Weight-based calculation: Patient is 100 kg 0.5 u/kg for TDD = 50 units; give half as basal (25 units long-acting basal analog at bedtime, 25 units as mealtime insulin divided at each meal [8 units rapidacting analog three times daily when food served) 37 Modifications to Therapy Nursing is instructed to hold the rapid-acting insulin if the meal is missed or the glucose level is low Correctional insulin is ordered to be added if the glucose level exceeds the target glucose range 38 19

20 Case Study (Cont.) The patient goes for an X-ray at 11:45 am The lunchtime dose of insulin has already been administered During the procedure, she feels shaky and panicky Point of care blood glucose testing reveals a blood glucose level of 68 mg/dl 39 Hypoglycemia Should be Defined as? 1. < 50 mg/dl 2. < 70 mg/dl 3. < 90 mg/dl 40 20

21 Essential Part of Insulin Therapy: Hypoglycemia Protocol Clear definition of hypoglycemia (BG < 70 mg/dl) Nursing order to treat without delay Stop insulin infusion (if patient is on one; unless T1DM) Oral glucose (if patient is able to take oral) IV dextrose or glucagon (if patient is unable to take oral) Repeat blood glucose (BG) monitoring 15 min after treatment for hypoglycemia and repeat treatment if BG not up to target Directions for when and how to restart insulin Look for the cause of hypoglycemia and determine if other treatment changes are needed Moghissi ES, et al. Endocr Pract. 2009;15(4):1-17. Moghissi ES, et al. Diabetes Care. 2009;32(6): Example Hypoglycemia Protocol If patient CAN safely swallow without aspirating If patient CANNOT safely swallow or patient has NPO status If BG mg/dl: Give 4 oz. juice or regular soda If BG mg/dl: Give 1 dose D50W IV push If BG 49mg/dL: Give 8 oz. juice or regular soda If BG 49mg/dL: Give 1 dose glucagon IM Recheck BG in min. If BG <70 mg/dl, then continuously repeat until BG 70 mg/dl and notify provider. Once BG >70 mg/dl, repeat BG monitoring in 1 hour and check again in 2 hours. Notify provider of insulin adjustments and changes in BG monitoring. If BG level has not remained 70 mg/dl for both BG checks, notify provider for further insulin adjustments and changes in BG level monitoring Roe ED, Raskin P. Hosp Pract. 2012; 40;

22 Case Study, cont d The patient is given 4 oz. of orange juice Repeat blood glucose check shows BG = 100 mg/dl Her insulin regimen is resumed A review of the day s BG levels shows that, except for the x-ray incident, no BG < 90 mg/dl and there were some BG 180 mg/dl 43 How would you adjust her dose? 1. Keep the same dose 2. Increased dose by 10% 3. Decrease dose by 10% 44 22

23 Daily Dose Adjustment Determine yesterday s total insulin dose actually administered Review yesterday s glycemic control Calculate today s scheduled insulin dose Some BG < 90 mg/dl 80% of yesterday s total BG mg/dl 100% of yesterday s total Some BG 180 mg/dl, no BG < 90 mg/dl 110% of yesterday s total McDonnell M, Donahue MACP Hospitalist. 2009; Transition to outpatient status 23

24 Case Study 56-year old obese female status post hysterectomy diagnosed with type 2 diabetes during hospitalization (A1C 8%) 120 kg During hospitalization, she was treated with 30 units basal insulin analog; 10 units rapid acting insulin at each meal FBG = 110 mg/dl, PPG = 125 mg/dl 47 Case Study: With what antihyperglycemic therapy would you discharge this patient? Basal bolus insulin Basal insulin + metformin Premixed insulin Metformin only Diet + exercise only 48 24

25 Transition to Outpatient Status Begin discharge planning early Stabilize blood glucose prior to discharge Obtain A1C for discharge planning if the result is not available from the previous 2 to 3 months A1C can now be used as a means to make the diagnosis of diabetes EL4, expert opinion 49 Discharge Planning: New Hyperglycemia A1C <5.7% 5.7% to 6.4% 6.5% to 7% 7% to 9% >9% General Guidelines Patient does not have diabetes nor pre-diabetes Patient has pre-diabetes (at risk); follow-up advisable; consider diabetes prevention strategies Patient has diabetes; can be treated with lifestyle/consider metformin Patient has diabetes and pharmacotherapy is indicated Most patients would likely benefit from basal-bolus insulin regimen at discharge OGTT = oral glucose tolerance test. Society of Hospital Medicine Glycemic Control Task Force. Workbook for Improvement

26 Discharge Planning: Diagnosed Diabetes A1C <7% 7% to 8% General Guidelines Continue pre-admission diabetes management therapy plan Increase dose of preadmission diabetes medications and/or add a second/third oral agent or basal insulin at bedtime >8% If on 2 diabetes medications, add basal insulin at bedtime >9% to 10% Most patients should be on basal-bolus insulin at discharge Society of Hospital Medicine Glycemic Control Task Force. Workbook for Improvement Case Study With an A1C of 8%, this patient will likely benefit from insulin therapy The choice of insulin regimen may depend on her lifestyle, education, support system, motivation 52 26

27 Transition from Hospital to Home Reinstitute preadmission insulin regimen or oral and non-insulin injectable antidiabetic drugs at discharge for patients with acceptable preadmission glucose control Initiation of insulin administration in those for whom it is indicated at least one day before discharge to allow assessment of the efficacy and safety of this transition Patients and their families/caregivers receive both oral and written instructions regarding their glycemic regimen 53 Transition to Outpatient Status Provide instruction Medication use / Injection technique if using insulin Basics on diet plan Glucose monitoring Hypoglycemia prevention and treatment Refer patient to a certified diabetes educator, if needed Clarify insurance reimbursement to ensure availability of medications at discharge Schedule a follow-up visit with clinician (& emergency number to call if problems) Moghissi ES, et al. Endocr Pract. 2009;15: EL4, consensus

28 Survival Skills to Be Taught Before Discharge How and when to take medication/insulin What to expect from the medication How/when to test BG (SMBG) What are target glucose levels Basics on meal planning How to treat hypoglycemia Sick-day management plan Date/time of follow-up visits Including diabetes education When and who to call on the healthcare team What community resources are available Moghissi E, et al. Endocr Pract. 2009;15: Umpierrez GE et al. J Clin Endocrinol Metab, 2012, 97: Gaps in US Hospital Discharge Planning and Transitional Care Base: Adults with any chronic condition who were hospitalized in past 2 years 2008 Commonwealth Fund International Health Policy Survey of Sicker Adults (data collection: Harris Interactive, Inc.)

29 Use of insulin pumps in the hospital Case Study 41-year old male presents to surgical unit for elective surgery; has been steadfast insulin pump user for 15 years A1C =6.2% Wishes to maintain control of insulin therapy during hospital stay 58 29

30 Do you allow patients to use insulin pumps during hospitalization? 1. Yes 2. No 3. Don t know 59 Insulin Pump Use During Hospitalization With increasing utilization of insulin pump therapy, many institutions allow patients on insulin pumps to continue using these devices in the hospital Others express concern regarding use of a device unfamiliar to staff, particularly in patients who are not able to manage their own pump therapy Which scenario best describes your institution? 60 30

31 Overview of Insulin Pump Therapy Electronic devices that deliver insulin through a SQ catheter basal rate (variable) + bolus delivery for meals Used predominately in Type 1 diabetes, though many Type 2s use CSII Pumpers tend to be very fastidious about their glycemic control They are often reluctant to yield control of their diabetes to the inpatient medical team Generally speaking, hospital personnel are unfamiliar with the workings of insulin pumps Hospitals do not stock infusion sets, batteries, etc. for insulin pumps (4+ brands on market) 61 Insulin Pump Use During Hospitalization Clear policies and procedures should be established at the institutional level to guide continued use of the technology in the acute care setting The availability of hospital personnel with expertise in continuous sc insulin infusion therapy is essential A formal Inpatient Insulin Pump Protocol reduces confusion and treatment variability Umpierrez et al, Endocrine Society Non-ICU Guideline. J Clin Endocrinol Metab Jan;97(1):

32 Insulin Pump Policy : Main Elements Patient qualifications for self-management (normal mental status, able to control device, etc.) Pump in proper functioning order and supplies stocked by patient/family Patient contract / agreement to be signed Order set entry Documentation of doses delivered (pump flow sheet) Ongoing communication between patient and RN Policies re: procedures, surgeries, CTs, MRIs, etc. 63 Insulin Pump Use During Hospitalization Patients who use continuous sc insulin infusion pump therapy in the outpatient setting can be candidates for diabetes -management in the hospital, provided that they have the mental and physical capacity to do so It is important that nursing personnel document basal rates and bolus doses on a regular basis (at least daily) Patient Attestation I confirm that I have been fully trained on the use of my insulin pump prior to this hospitalization and that I am capable and willing to manage it independently during my hospital stay. If at any time I feel that I am unable to manage the pump, I will alert my medical team. Requires patient and witness signature Bailon RM et al Endocrine Practice. 2009;15:25. EL3, retrospective chart review Noschese ML et al Endocrine Practice. 2009;15:415. EL3, review of medical records; EL4, expert opinion 64 32

33 A Validated Inpatient Insulin Pump Protocol Physician Order Set Consult Diabetes Service / Endocrinologist Discontinue all previous insulin orders Check capillary blood glucose frequency Patient to self-administer insulin via pump Patient to document all BG and basal/bolus rates Insulin type order for pump: rapid-acting analogue (lispro, aspart, glulisine) Set target BG range Implement hypoglycemia treatment protocol Noschese et al. Endocrin Pract. 2009;15: A Validated Inpatient Insulin Pump Protocol Basal Insulin Rates Start Time Stop Time Basal Rate Units/hr Start Time Stop Time Basal Rate Units/hr Start Time Stop Time Basal Rate Units/hr 12 am 1 am am 9 am pm 5 pm am 2 am am 10 am pm 6 pm am 3 am am 11 am pm 7 pm am 4 am am pm 8 pm am 5 am pm pm 9 pm 6 am 12 pm 8 pm 5 am am 2 pm 10 pm 6 am 1 pm 9 pm pm 8 am 3 pm 10 pm 7 am 2 pm 3 pm 4 pm pm 12 am 0.7 Patient to self-administer insulin via SQ insulin pump and document all basal rates. Noschese et al. Endocrin Pract. 2009;15:

34 A Validated Inpatient Insulin Pump Protocol Meal Boluses based on: Carbohydrate count Fixed doses Breakfast u/per gram u at Breakfast Lunch u/per gram Supper or u/per gram u at Lunch u at Supper u with Snacks Snacks u/per gram Correction boluses: unit(s) for every mg/dl over mg/dl (target glucose) Noschese et al. Endocrin Pract. 2009;15: A Validated Inpatient Insulin Pump Protocol 50 patient hospitalizations after implementation of an Inpatient Insulin Pump Protocol (IIPP) 3 groups: Mean BG (mg/dl) Group 1 - IIPP+DM consult (34) 173 ±43 Group 2 - IIPP alone (12) 187 ±62 Group 3 - Usual care (4) P=NS 218 ±46 More inpatient days with BG>300 in Group 3 (p<0.02.) No differences in inpatient days with BG<70 1 pump malfunction; 1 infusion site problem; no SAEs 86% of pumpers expressed satisfaction with ability to manage DM in the hospital Noschese et al. Endocrin Pract. 2009;15:

35 Inpatient Insulin Pump Therapy: A Single Hospital Experience 65 patients (125 hospitalizations) Age (mean) 57 ±17 yrs; DM duration 27 ±14 yrs, pump use 6 ±5 yrs; A1C 7.3 ±1.3%; LOS 4.7 ±6.3days Pump therapy continued 66% Endocrine consults in 89% Consent agreements in 83% Pump order sets completed in 89% RN assessment of infusion site in 89% Bedside insulin pump flow sheets in only 55% Mean BG 175 mg/dl (same as off pump) No AEs (one catheter kinking) Nassar et al. J Diab Sci Technol. 2010;4: Summary Optimizing Care of the Inpatient with Hyperglycemia is Challenging! Inpatient situations are unstable No single algorithm is suitable for all patients Many scenarios require increased monitoring and possible adjustments in insulin dose Transitions in care are important opportunities to reassess glycemic control 70 35