Patient Self-Management of Diabetes Care in the Inpatient Setting

Abstract

Self-management of diabetes by inpatients can be problematic. People with type 1 diabetes often prefer to self-manage their diabetes in the inpatient setting. We report the case of a patient admitted to the surgical service who was self-administering his home insulin, often without telling his nurse or physician. He was aiming for tight glycemic control, which resulted in life-threatening hypoglycemia. While patients can often self-manage their diabetes in the outpatient setting, inpatient management of diabetes is very different. Patients may not be familiar with common scenarios requiring adjustments of insulin therapy. Therefore, we recommend against self-management of diabetes in the hospital. However, the patients should be involved in discussions about management of their diabetes in the hospital to allay their concerns about changes made to their insulin regimens. An example of successful cooperative management is with use of protocols that allow continued use of insulin pumps in the hospital.

Case

A 60-year-old male with type 1 diabetes (T1DM) since 1981 and a history of pancreatic insufficiency (with large volume stools and obstructed defecation resulting in repeated colostomies and reversals) was admitted to the surgical service for reversal of his prolapsed colostomy. The endocrinology service was consulted to assist with diabetes management.

In regards to his T1DM history, the patient experienced frequent hypoglycemia (up to 3-4 times a day) including nocturnal hypoglycemia, severe hypoglycemic episodes, and hypoglycemic unawareness. He used lente insulin from England as his basal insulin and both regular and lispro insulin with meals. He stated that glargine and neutral protamine Hagedorn (NPH) insulin did not work well for him.

Postoperatively, the patient was started on an intravenous (IV) insulin infusion with good glycemic control initially. However, after seeing a rise in his glucose, he insisted that the infusion rate be increased (against protocol) and as a result, the patient was hypoglycemic at 35 mg/dL the following morning. Later that morning, insulin vials (lente and regular) and insulin syringes were found at the patient’s bedside. He refused to give them to the nurse to store and insisted on self-managing his diabetes. He insisted on coming off of the insulin infusion, and since the team was concerned that the patient had already injected his own long-acting insulin, he was initially placed on just correctional insulin dosing by the surgical team. He subsequently refused several fingerstick glucoses, and he continued to have very tight glycemic control (with glucoses in the 70s-80s) and early morning hypoglycemia. The staff suspected that the patient was self-administering his home insulin. Eventually, risk management was involved and a compromise was reached. The team agreed to let the patient self-administer his lente insulin if the pharmacy could store it and then bring it to him when the dose was due. The team also placed the patient on regular insulin with meals and an aspart insulin correctional scale. Despite the fact that this was done, the patient continued to have early morning hypoglycemia. Soon thereafter, he was discharged home with a plan for him to follow-up with his outpatient endocrinologist. His outpatient regimen of lente, regular, and lispro insulin was not changed at the time of discharge.

Commentary

Twenty-five years ago, at an inpatient diabetes committee meeting, our senior endocrinologist stated that the safest way to manage diabetes in hospitalized patients was to allow the patients and their family members to manage the diabetes. However, this was a time when there was limited use of bedside glucose monitoring, when sliding scale insulin was used (regardless of when patients would eat), and when patients had longer hospital stays for less acute illnesses. Times have changed.

Just as pediatric patients are not just small adults, inpatients with diabetes are not the same as outpatients with diabetes. Treatment options, goals and patients themselves are different. Patients are sick, may be on glucocorticoids, and may have evolving renal function among other things. Below, we discuss why inpatient self-management of diabetes is not the best approach.

Adult patients with T1DM often self-manage their disease as outpatients and feel competent and confident in their ability to do so. However, when hospitalized, management of their diabetes is mainly dictated by nurses, physicians, and diabetes educators. Many patients with T1DM prefer to continue to self-manage their diabetes in the hospital. Germain and Nemchik ¹ showed that 79% of patients with T1DM supported self-management in the hospital, and 92% of patients were concerned about their diabetes management during future hospitalizations given that they felt insecure about providers’ ability to manage the disease. They also expressed fear of hypoglycemia and limited food access ¹ given on average a 93-minute lag between blood glucose monitoring and insulin administration. ² Therefore, the concern that patients with T1DM express surrounding glucose management in the hospital is understandable.

The UK National Health Service (NHS) encourages self-administration of diabetic medication in the hospital in collaboration with health care providers to promote patient autonomy. ³ However, the staff feels ambivalent about this measure, especially given the time needed to assess whether a patient can do this. ³ Furthermore, there is currently a dearth of literature on how to best evaluate an individual’s ability to self-manage diabetes in the hospital and therefore, one cannot support self-management of diabetes in hospitalized patients despite the fact that as outpatients, these individuals are often self-managing. ⁴

As we alluded to above, it is important to acknowledge that the inpatient and outpatient settings are very different, and this can lead to changes in glycemic control and hence, changes in insulin requirements. For example, it is well known that many patients are on high doses of basal insulin that cover not only their basal needs but also some of their prandial needs. If such patients are made NPO and are continued on their usual dose of basal insulin, they can become hypoglycemic. Insulin requirements often increase during an acute illness, ⁵ and patients are often not familiar with how to adjust their insulin doses in this setting. Inpatients often receive glucocorticoids or are started on enteral or parenteral nutrition. These are scenarios with which they are not familiar and where adjustment of insulin doses is required. Inpatients with acute onset of hepatic or renal dysfunction are at higher risk of developing hypoglycemia, and patients are often unaware of how this changes their insulin requirements.

In addition, while many patients will say they can self-manage their diabetes, there is no tool to measure their ability to do so. Patients may be on medications that alter mental status, and they may also be physically incapable of managing injections (such as in the postoperative setting), which can impact their ability to self-manage their diabetes. Furthermore, the glycemic control a patient is aiming for is often tighter than the glycemic control inpatient providers are aiming for. As outpatients, glycemic targets are 80-130 mg/dL in the fasting and preprandial state and <180 mg/dL in the postprandial state. ⁶ However, based on the NICE SUGAR study ⁷ and current guidelines,^8,9 providers aim for glucoses in the mid- to high-100s in inpatients. In addition, awareness and self-management of the disease improve with trial and error, ¹⁰ and this method is not supported in the hospital due to the associated risks to the patient, especially the risk of hypoglycemia, and hospital liability.

There are also other factors to consider. A patient self-managing their diabetes may take extra insulin doses, which can lead to stacking of insulin and subsequently, hypoglycemia, as it did in this patient. In addition, if the patient experiences an adverse event as a result of their diabetes self-management, providers will be unaware of what, when, and how much insulin was administered. This makes caring for the patient challenging.

Patients on Insulin Pumps

Patients on insulin pumps are often even more involved in self-management of their diabetes. Therefore, they are often even more reluctant to relinquish control of their diabetes to health care providers when they are hospitalized. A commentary written by a patient ¹¹ strongly advocated for continued use of insulin pumps in the hospital as he was horribly mismanaged when taken off of his pump and when allowed to remain on his pump, he achieved good glycemic control. However, nurses are often unfamiliar with insulin pumps and how to operate them. Hence, there is discomfort from both sides.

In fact, Nassar et al ¹² demonstrated that in the perioperative setting, there was inconsistent documentation of pump use and glucose monitoring. However, implementation of an inpatient insulin pump protocol (IIPP) led to good results. ¹³ We agree that patients can continue using their insulin pumps in the hospital, and we follow a standardized protocol that allows this to be done safely at the University of California, San Francisco.

Conclusions

While many diabetic patients, especially those with T1DM, are comfortable self-managing their diabetes as outpatients, new variables are introduced in the inpatient setting. Patients are often not familiar with how these variables affect their insulin needs. In addition, there is no standardized tool to assess each patient’s self-management skills. Glycemic targets in the hospital are also different. And more importantly, self-management of diabetes in the hospital can lead to adverse consequences, especially severe hypoglycemia, which has health and legal implications. Therefore, in the hospital, health care providers, including nurses, physicians, and diabetes educators, should manage diabetes. However, patients should be part of the discussion so that they too can share their knowledge. Insulin pumps are a special circumstance, and standardized protocols for continued use in the hospital have worked well and resulted in provider and patient satisfaction.