Hyperglycemia management using insulin in the acute care setting: therapies and strategies for care in the non-critically ill patient.

BACKGROUND: Hyperglycemia is prevalent in hospitalized non-critically ill patients and is associated with higher morbidity and mortality. Poor glycemic control is related to elevated costs due to longer hospital stays and higher rates of complications.

OBJECTIVE: To review current literature evaluating treatment strategies for management of hyperglycemia in the non-critically ill hospitalized patient and to discuss the role of pharmacists in glycemia management.

DATA SOURCES: A literature review (January 2000-January 2010) was conducted via PubMed, Web of Science, Cumulative Index to Nursing and Allied Health, the Cochrane Library, Combined Health Information Database, and Education Resources Information Center. MeSH terms for diabetes were used along with stress hyperglycemia, insulin therapy, and insulin analogs in combination with non-critically ill, hospitalized, acute care, or inpatient.

STUDY SELECTION AND DATA EXTRACTION: All articles identified from the data sources were reviewed for inclusion. Clinical trial reports, practice guidelines, and reviews involving insulin therapies and/or quality improvement initiatives for hyperglycemia in the acute care setting were evaluated. A total of 133 citations were reviewed and an additional 11 citations were identified from reference lists.

DATA SYNTHESIS: The association between hyperglycemia and increased mortality is recognized in the acute care setting among critically ill patients; however, data to support glycemia management in non-critically ill patients continue to be established. National consensus guidelines support strategies for glycemia control that focus on insulin therapy and treatment-driven protocols. These initiatives can result in quality improvement when led by multidisciplinary teams, including pharmacists. Literature supports a pharmacist role in glucose monitoring and insulin dosing.

CONCLUSIONS: Management of hyperglycemia is a critical component of acute care. Insulin treatment regimens and protocols for non-critically ill patients in the acute care setting are evolving with recognition of ideal glucose targets to prevent adverse outcomes. Glycemia management can be complex and presents opportunities for pharmacist involvement.