Inpatient diabetes management in non-ICU settings: evidence and strategies

The epidemic of diabetes and results from several recent trials demonstrating the benefits of intensive glycemic control in the ICU setting have focused attention on inpatient glycemic control on general hospital wards, where over 25% of patients have diabetes. Current management of inpatient glycemia is haphazard, relying on corrective doses of insulin after hyperglycemia has occurred (the insulin "sliding scale"). Although data to guide evidence-based management of inpatient glycemia in non-critically ill patients are scant, the American College of Endocrinology and the American Diabetes Association have advocated more intensive therapy in the general inpatient setting, and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has followed suit, launching an initiative on inpatient glycemic control. Extrapolation from basic and clinical studies suggests that improved diabetes management in general medical settings is likely to be beneficial, though the appropriate intensity of glycemic control in non-ICU settings has yet to be determined. Independent of the acute impact of inpatient glycemia, inpatient diabetes management is also important because hospitalization offers an opportunity to optimize care upon discharge for patients with poorly controlled diabetes. Finally, systems-level strategies likely to improve inpatient diabetes management are reviewed.