A new clinical practice guideline published in the January 2012 issue of the Journal of Clinical Endocrinology and Metabolism includes the recommendation that everyone admitted to the hospital have blood glucose testing performed. The evidence-based guideline was developed by a panel convened by The Endocrine Society made up of experts in the field of hyperglycemia (high blood glucose, the major body sugar). The panel carried out a critical review of a large number of research papers to assess the strength and quality of evidence about the diagnosis and treatment of hyperglycemia in hospitalized patients not in intensive care. The aim was to develop guidelines on the management of hyperglycemia in hospitalized patients to improve care for those with hyperglycemia and diabetes.
Studies have shown that about one-third of hospital patients on general wards, not exclusively diabetics, have hyperglycemia. Causes include the physical stress of illness, trauma or surgery, lack of mobility, drugs including steroids like prednisone, not taking medications for known diabetes, and liquid feeding either by a stomach tube or into a vein. Patients with untreated hyperglycemia have a longer hospital stay, have slower wound healing, get more infections, are more disabled after discharge from hospital, and have a higher risk of dying.
The guideline suggests that all patients, whether they are known to have diabetes or not, should have a test for blood glucose on admission to a hospital. It recommends that those with concentrations greater than 140 mg/dL (7.8 mmol/L) should be monitored for 24 to 48 hours using a bedside point-of-care (POC) glucose meter and should receive treatment with insulin if the raised levels persist. If the initial measurement is greater than 140 mg/dL, hemoglobin A1c should be measured as well (unless tested in the preceding two or three months) to help identify those with undiagnosed or inadequately treated diabetes. The guideline goes on to give detailed targets for glucose levels and treatment protocols to help attain them.
However, there are concerns that the guidelines do not address hyperglycemia that may develop after admission and the initial glucose test. As noted earlier, hyperglycemia may develop later in the hospital stay due to stress of illness, and this may be missed if only one test is performed upon admission. Some have also challenged the guidelines given concerns with the accuracy of hand-held glucose meters, which use capillary blood from a fingerstick rather than a blood sample from a vein. Although the guidelines state that POC testing has some advantages in terms of identifying patients in need of changes to their treatment to maintain good glycemic control and that the glucose meters are calibrated to be compatible with tests performed in laboratories, some experts remain unconvinced in that regard.
In particular, several members of the National Academy of Clinical Biochemistry (NACB) committee for the Guidelines and Recommendations for Laboratory Analysis in the Diagnosis and Management of Diabetes Mellitus have expressed concern, including chair of the committee Dr. David Sacks, who stated, "the panel said POCT has some advantages over lab venous glucose testing. I found that section very unpersuasive, and I don't think it has advantages, other than results being available immediately. However, if the results aren't accurate, then you can make treatment and management errors." (CLN Feb 2012; 38(2)). The need remains to examine the accuracy of these glucose meters when used in the hospital.
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Guillermo E. et al. Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Setting: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism January 1, 2012 vol. 97 no. 1, 16-38. Available online at http://jcem.endojournals.org/content/97/1/16.abstract through http://jcem.endojournals.org. Accessed March 2012.
Rollins, G. Panel Advises Blood Glucose Testing in All Hospitalized Patients. Are Glucose Meters Accurate Enough to do the Job? Clinical Laboratory News. February 2012. Available online at http://aacc.org/publications/cln/2012/February/Pages/GlucoseTesting.aspx through http://aacc.org. Accessed March 2012.