I’ve spent the last few weeks working with the metabolic support team and shadowing the diabetes team at a large hospital in western North Carolina.
Here are 5 things I’ve learned so far about diabetes management in the hospital:
1. Diabetes Knowledge is Limited
We expect our providers to know everything about every condition, but few providers know much beyond the basics of diabetes management unless they specialize in endocrinology or diabetes management (endocrinologists, CDEs…).
A surprising number of medical professionals don’t really understand the difference between different types of diabetes. I once saw multiple notes describing a pregnant woman with type 1 diabetes who was “successfully treated with Metformin.” While Metformin has on rare occasions been prescribed in conjunction with insulin for people with type 1 diabetes, Metformin alone most certainly will not “successfully treat” someone with type 1 diabetes. That’s just 1 example of many I’ve seen and heard so far. To be fair, I had never heard of cystic fibrosis related diabetes before I did my pediatrics rotation.
2. Type of Diabetes is not always Clear or even Considered in Treatment
More often than not, type of diabetes is not actually specified in the medical record, and sometimes prediabetes or steroid induced hyperglycemia get documented as diabetes, which can make things challenging for anyone responsible for managing blood glucose levels in the hospital. That being said, pretty much everyone in the hospital with elevated blood glucose levels is treated with insulin regardless of whether they have type 2, type 1, or steroid or stress related hyperglycemia. The focus is really on keeping blood glucose levels within a specific range for decreased risk of infection and/or complications of treatment.
3. Pumps and CGMs
We have a lot of great technology that have been available for a while now, but pumps and CGMs still seem to confuse a lot of practitioners in the inpatient setting. Pumps are removed for most procedures & patients typically must sign a waiver if they wish to use a pump in the hospital, and only if practitioners believe the patient is stable enough to manage his/her own blood sugars.
You would think that CGMs would be a great tool in the hospital, as many practitioners are concerned about risk of hypoglycemia with use of insulin in the hospital setting. That being said, blood glucose is typically monitored with finger pricks at specific increments throughout the day. Frequency of finger pricks often varies by floor, and some people may only get their blood sugar checked once a day if they’ve been pretty stable. If blood sugars are trending lower than ideal dextrose may be given or insulin may be decreased. I’ve seen very few patients with CGMs, but those I did see were allowed to keep their CGM on, and asked to report blood sugars to the nurse when asked.
4. Glycemic Targets Differ by Condition
There are different glycemic targets for different conditions and different floors. On oncology and renal, targets are typically higher 150-250 mg/dL, while on cardiology the target range is 100-150. That being said, most practitioners don’t really bat an eye, unless blood sugars are running over 200. A number of surgeons have also caught on to the research showing slower healing and increased risk of infection/complication with hyperglycemia, so some surgeons may prefer more tightly controlled sugars in the hospital than others.
5. Meds can make things Messy
People react very differently to stress and steroids while in the hospital. Some people’s insulin needs triple or quadruple when put on a steroid and others barely react. This makes it extremely hard to predict blood sugars in hospitalized patients. Medications also change all the time. Steroids and dosing may change suddenly and it may take a little while for the diabetes team to get flagged and adjust insulin doses. Additionally, some meds are given in dextrose, which will certainly spike blood sugars.
How to advocate for yourself
- Do your research, ask questions, and understand that while you may be most concerned with your diabetes management, a provider may be more focused on another aspect of your care that may be more critical at a given moment.
- If possible, discuss your management and care goals with someone close to you who you trust to advocate for you.