Editors Rajesh Garg MD
Assistant Professor Department of Medicine Division of Endocrinology, Diabetes and Hypertension Brigham and Women's Hospital Harvard Medical School Boston, MA, USA
Margo Hudson MD
Instructor Department of Medicine Division of Endocrinology, Diabetes and Hypertension Brigham and Women's Hospital Harvard Medical School Boston, MA, USA
Foreword Deborah J Wexler MD MSc
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Hyperglycemia in the Hospital Setting
First Edition: 2014
9789351523130
Printed at
5Dedicated to
Our teachers who imparted to us
the gift of knowledge and
our patients who keep challenging us over time
7Contributors
- Adriana C Holman bsc md
- Signature Nutrition Fellow
- Metabolic Support Services
- Department of Trauma, Burn and Surgical Critical Care
- Brigham and Women's Hospital
- Harvard Medical School
- Boston, MA, USA
- Ajay Chaudhuri mbbs mrcp
- Associate Professor
- Department of Medicine
- University at Buffalo
- The State University of New York
- Buffalo, New York, USA
- Aleksandar S Mijailovic bs
- Research Assistant
- Department of Neurology
- Beth Israel Deaconess Medical Center
- Boston, MA, USA
- Andrea G Dooley-Wood pharmd bcacp
- Clinical Pharmacy Specialist
- Lancaster General Hospital
- Lancaster General Health
- Lancaster, Pennsylvania, USA
- David P Reardon pharmd bcps
- Clinical Pharmacy Specialist—Critical Care
- Brigham and Women's Hospital
- Harvard Medical School
- Boston, MA, USA
- Donald C Simonson md mph scd
- Associate Professor
- Division of Endocrinology, Diabetes and Hypertension
- Brigham and Women's Hospital
- Harvard Medical School
- Boston, MA, USA
- Graham T McMahon
- mb md mmsc frcpi
- Associate Professor
- Department of Medicine
- Division of Endocrinology, Diabetes and Hypertension
- Brigham and Women's Hospital
- Harvard Medical School
- Boston, MA, USA
- Jeffrey L Schnipper md mph
- Director
- Department of Clinical Research
- BWH Hospitalist Service
- Brigham and Women's Hospital
- Harvard Medical School
- Boston, MA, USA
- Associate Professor
- Department of Medicine
- Harvard Medical School
- Boston, MA, USA
- Lisa B Cohen pharmd cde
- Associate Professor
- Department of Pharmacy Practice
- College of Pharmacy
- University of Rhode Island
- Kingston, RI, USA
- Manav Batra mbbs
- Fellow
- Division of Endocrinology
- University at Buffalo
- Diabetes Endocrinology Centre of Western NY
- Amherst, NY, USA
- Margo Hudson md
- Instructor
- Department of Medicine
- Division of Endocrinology, Diabetes and Hypertension
- Brigham and Women's Hospital
- Harvard Medical School
- Boston, MA, USA
- Naomi Shimizu md
- Instructor
- Department of Surgery
- Brigham and Women's Hospital
- Harvard Medical School
- Boston, MA, USA
- Nitesh D Kuhadiya md mph
- Assistant Professor
- Department of Medicine
- Section of Endocrinology, Diabetes and Metabolism
- Diabetes and Endocrinology Centre of Western New York
- Buffalo, NY, USA
- Paresh Dandona
- mbbs phd frcp facp facc
- Director
- Diabetes Endocrinology Center of Western NY
- Chief of Endocrinology
- SUNY at Buffalo
- Diabetes Endocrinology Centre of Western NY
- Amherst, NY, USA
- Paul M Szumita pharmd bcps
- Clinical Pharmacy Practice Manager
- Director
- PGY-2 Critical Care Pharmacy Residency
- Brigham and Women's Hospital
- Harvard Medical School
- Boston, MA, USA
- Rajesh Garg md
- Assistant Professor
- Department of Medicine
- Division of Endocrinology, Diabetes and Hypertension
- Brigham and Women's Hospital
- Harvard Medical School
- Boston, MA, USA
- Rita Marie McCarthy msn anp cde
- Nurse Practitioner (Diabetes)
- Brigham and Women's Hospital
- Harvard Medical School
- Boston, MA, USA
- Sonia R Freitas pharmd bcacp cde
- Clinical Pharmacist
- Brigham and Women's Advanced Primary Care
- South Huntington
- Jamaica Plain, MA, USA
- Stacy Melanson md phd
- Associate Medical Director
- Clinical Chemistry
- Brigham and Women's Hospital
- Harvard Medical School
- Boston, MA, USA
- Vihas Patel md facs cnsc
- Director
- Metabolic Support Service
- Brigham and Women's Hospital
- Harvard Medical School
- Boston, MA, USA
Once the exclusive concern of endocrinologists and disregarded by many others, management of Hyperglycemia in the Hospital Setting has become the standard of care. Three major developments since the start of this century have come together to support this advance.
First, the publication of a seminal study of intensive insulin treatment in Belgian surgical intensive care unit (ICU) patients in 2001 focused enormous attention on the appropriate treatment of hyperglycemia in critically ill patients. The pendulum has swung several times since that publication between various approaches and treatment targets in intensive care settings. Nonetheless, it is fair to say that seminal paper, which showed a significant mortality benefit, gave rise to randomized trials outside the intensive care setting. The safety and efficacy of basal-bolus insulin regimens in general medical and surgical care settings in the improving outcomes has launched widespread efforts to manage hyperglycemia.
Second, the quality and safety movement, which has grown exponentially over the past decade, necessarily took up insulin, one of the top five medications associated with medical error, as a priority area. Approaches to improve quality and safety of insulin use have included educational efforts, standardized order sets, and team-based care to manage complex insulin regimens in the hospital setting. These efforts have been led by hospitalists, pharmacists, and nurses in addition to endocrinologists.
Finally, and most recently, the recognition of the importance of transitions of care between hospital and home, and the role of the acute inpatient admission as one point on the continuum of care within an accountable care organization context, has promoted attention to the need to extend the lessons of the quality and safety interventions beyond the acute setting.
Hyperglycemia in the Hospital Setting spans the progress in all of these areas to provide a comprehensive guide to this ever-challenging, and now widely accepted, goal in the care of all of our patients.
Deborah J Wexler md msc
Assistant Professor
Department of Medicine Harvard Medical School
Co-Clinical Director Massachusetts General Hospital Diabetes Center
Boston, MA, USA
11Preface
Over many years working together on a team dedicated to diabetes management, we have learned a great deal about glucose management in hospitalized patients. While we have seen the field evolving over time, we also have noticed a dearth of books devoted to this topic. Hyperglycemia in the Hospital Setting, we believe will be a comprehensive and practical source of information on management of glucose in the inpatient setting. We hope to fill the void by addressing the major commonly encountered situations with straightforward information on physiology and treatment plans that we know are effective, while reviewing current literature on these topics and some of the remaining controversies.
The book is evidence-based with expert opinion provided where necessary. We begin with a discussion of the epidemiology of hyperglycemia in hospitalized patients and then proceed to a discussion of the current evidence for harm caused by hyperglycemia. We follow with a discussion of glucose monitoring and situations which may interfere with it. We next tackle the controversial topic of glucose goals for hospitalized patients followed by management strategies to achieve these goals. The next three chapters focus on the specific situations of patients on nutritional support, hyperglycemic emergencies and hypoglycemia. Finally, we end with discussions of the team approach to inpatient glucose management, using hospitalization as a time to improve patient education and to improve outpatient care by improving discharge planning. Improving patient outcomes is at the core of the book.
We hope that physicians, pharmacists, physician assistants, and nurses at all levels of training will find the book useful.
Rajesh Garg
Margo Hudson
13Acknowledgments
We wish to acknowledge the team members of Diabetes Management Service at the Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA, who have contributed to Hyperglycemia in the Hospital Setting either directly by writing chapters or indirectly by sharing their experiences with us. Through a shared team work, we gained the experience and knowledge that have formed the core of the book. Rita Marie McCarthy, Nurse Practitioner and Samira Sheth, Nurse Practitioner helped us to manage the heavy load of patient care while we worked on the book. We also acknowledge the professional support and advice of our colleagues, Merri Pendergrass Carolyn Becker, Graham T McMahon, and Alexander Turchin, who were always available to give a fresh viewpoint on a wide range of topics. Finally, we acknowledge our spouses Neeta Garg, and Jim Hudson, who offered many suggestions throughout the process to make this a better book.