Hospital Admission Guidelines for Diabetes Mellitus

Hospital Admission Guidelines for Diabetes Mellitus

These guidelines are to be used for determining when a patient requires hospitalization for reasons related to diabetes. Inpatient care may be appropriate in the following situations:

Life-threatening acute metabolic complications of diabetes.

Newly diagnosed diabetes in children and adolescents.

Substantial and chronic poor metabolic control that necessitates close monitoring of the patient to determine the etiology of the control problem, with subsequent modification of therapy.

Severe chronic complications of diabetes that require intensive treatment or other severe conditions unrelated to diabetes that significantly affect its control or are complicated by diabetes.

Uncontrolled or newly discovered insulin-requiring diabetes during pregnancy.

Institution of insulin-pump therapy or other intensive insulin regimens.

Modification of fixed insulin-treatment regimens or sulfonylurea treatment is not, by itself, an indication for hospital admission.

Guidelines for hospital admission are given below. Guidelines are never a substitute for medical judgment, and each patient's total clinical and psychosocial circumstances must be considered in their application. Therefore, there may be situations in which admission is appropriate, although the patient's clinical profile does not comply with these guidelines. For example, inadequate family resources may dictate admission of newly diagnosed type 1 diabetic patients who otherwise do not meet the admission guidelines.

ACUTE METABOLIC COMPLICATIONS OF DIABETES Admission is appropriate for the following:

Diabetic ketoacidosis
Plasma glucose >250 mg/dl (>13.9 mmol/l) with 1) arterial pH <7.30 and serum bicarbonate level <15 mEq/l and 2) moderate ketonuria and/or ketonemia.

Hyperosmolar hyperosmolar state
Impaired mental status and elevated plasma osmolality in a patient with hyperglycemia. This usually includes severe hyperglycemia (e.g., plasma glucose >600 mg/dl [>33.3 mmol/l]) and elevated serum osmolality (e.g., > 320 mOsm/kg [>320 mmol/kg]).

Hypoglycemia with neuroglycopenia
1) Blood glucose <50 mg/dl (<2.8 mmol/l) and the treatment of hypoglycemia has not resulted in prompt recovery of sensorium; or 2) coma, seizures, or altered behavior (e.g., disorientation, ataxia, unstable motor coordination, dysphasia) due to documented or suspected hypoglycemia; or 3) the hypoglycemia has been treated but a responsible adult cannot be with the patient for the ensuing 12 h; or 4) the hypoglycemia was caused by a sulfonylurea drug.

UNCONTROLLED DIABETES
Poor metabolic control of established diabetes as defined herein justifies admission if it is necessary to determine the reason for the control problems and to initiate corrective action. For admission under these guidelines, documentation should include at least one of the following:

Hyperglycemia associated with volume depletion.

Persistent refractory hyperglycemia associated with metabolic deterioration.

Recurring fasting hyperglycemia > 300 mg/dl (> 16.7 mmol/l) that is refractory to outpatient therapy or a glycated hemoglobin level of > 100% above the upper limit of normal.

Recurring episodes of severe hypoglycemia (i.e., < 50 mg/dl [ < 2.8 mmol/l]) despite intervention.

Metabolic instability manifested by frequent swings between hypoglycemia (< 50 mg/dl [< 2.8 mmol/l]) and fasting hyperglycemia (> 300 mg/dl [ > 16.7 mmol/l]).

Recurring diabetic ketoacidosis without precipitating infection or trauma.

Repeated absence from school or work due to severe psychosocial problems causing poor metabolic control that cannot be managed on an outpatient basis.

ADMISSION FOR COMPLICATIONS OF DIABETES OR FOR OTHER ACUTE MEDICAL CONDITIONS Chronic cardiovascular, neurological, renal, and other diabetic complications may progress to the stage where hospital admission is appropriate. In these situations, the needs governing admission for the complication per se (e.g., management of end-stage renal disease) are the primary guidelines for determining whether inpatient care is required.

A 27-year-old man with newly diagnosed acute myelogenous leukemia spikes a temperature to 38.7C (101.7F) on the sixth day of induction therapy. He feels well and has no physical complaints. His only medicine is intravenous cytosine arabinoside, 140 mg every 12 h. Physical examination is unrevealing. His white blood count is 900/L, of which 10 percent are granulocytes and the rest mostly lymphocytes; platelet count is 24,000/L. Findings on chest x-ray and urinalysis are normal.
After obtaining appropriate cultures, the man's physician should

A observe closely for the development of a clinically evident source of fever
B begin antibiotic therapy with gentamicin and mezlocillin
C begin granulocyte transfusion and antibiotic therapy with gentamicin and mezlocillin
D begin gammaglobulin treatment and antibiotic therapy with gentamicin and mezlocillin
E begin antibiotic therapy with amphotericin, gentamicin, and mezlocillin

The answer is B
If not attacked promptly, infection in neutropenic patients can be quickly fatal. Often, these patients display neither the signs nor the symptoms of infection. Fever should be regarded as an indication of infection, and antibiotic therapy should begin immediately after appropriate cultures are obtained. An effective initial antibiotic regimen would consist of an aminoglycoside antibiotic or third-generation cephalosporin and a semisynthetic antipseudomonal penicillin. Gammaglobulin is of little benefit in the treatment of granulocytopenic cancer patients. Granulocyte transfusions are of no benefit. Amphotericin B is appropriate if granulocytopenia persists and defervescence does not occur after 7 days of antibacterial antibiotics, or sooner, if clinical deterioration is noted.

You are the ICU attending physician taking care of a 40-year-old gay man with AIDS who is intubated with his third bout of pneumocystis pneumonia. His condition is worsening steadily and he has not responded to appropriate antibiotic therapy. The patient's longtime partner, Richard, has a signed durable power of attorney (DPOA) and states that if the patient's condition becomes futile the patient would not want ongoing ventilation. As the ICU attending you decide that ongoing intubation is futile. You consult with Richard and decide to remove the patient from the ventilator to allow him to die in the morning. The patient's Roman Catholic parents arrive from Kansas and threaten a lawsuit if the ventilator is withdrawn.
There are several key questions which come out of this case:

Who is the legal decision maker here?
What are some of the pertinent social influences in this case?
Who are some other staff members who may be able to help?
How should the physician deal with any prejudices they have in this case?

What is the legal decision making status of a long-term partner?
Richard, the durable power of attorney is the legal decision maker in this case. The document is a legally binding agreement that states Richard is the final arbiter of all medical decisions once the patient becomes incapacitated. This creates a legal foundation for Richard to keep his role as the final medical decision maker in conjunction with the attending physician while allowing room for discussion with the family on this difficult topic.
How should I facilitate communication between family members?
This is an unfortunate situation for everybody involved. The physician can help diffuse this situation by trying to understand the different perspectives that each of the involved individuals brings to the situation. The family arrives to see their dying son and may be confronted with multiple issues for the first time. First they may be finding out that their son is gay, that he has AIDS, and that he is immanently dying all at the same time. Any of these issues may be a shock to the family, so it is important to keep this perspective in mind when making difficult care decisions and to communicate clearly and honestly with them. Communication regarding the patient's care should be consented to by the patient whenever possible.
Alternatively, individuals in the gay communities in metropolitan areas that have been severely affected by AIDS have watched many of their friends die of their disease and are very well educated about end of life issues. It is likely that Richard as your patient's DPOA has spent significant time considering these issues with the patient before becoming the patient's surrogate. His role as the patient's significant other is not legally defined in many areas of the United States at this time. This relationship is often the equivalent of marriage in the gay community and should be respected by the hospital personnel in all points of medical care.
Who are some other staff members who may be able to help?
This is a case where several members may help with the decision. ICU nurses often have experience and perspective in dealing with grieving families of terminally ill patients as do staff social workers or grief counselors. Another invaluable resource in this case is a hospital chaplain or spiritual counselor who may be able to provide spiritual support and guidance to the family. It is important here to find out what resources are available in the hospital for Richard and the patient's family and after discussing the case with them, seek help from these other skilled professionals. If you as a physician have cultivated a relationship with these services it is often appropriate to invite them to a family meeting so that they can help you focus the discussion on the care of the patient, who is always your first priority as a physician.
How should I deal with any prejudices I may have in this case?
Much has been written on the responsibility of the physician in taking care of the patient with AIDS. The AMA position is 'A physician may not ethically refuse to treat a patient whose condition is within the physician's realm of competence. neither those who have the disease or are infected by the virus should be subject to discrimination based on fear or prejudice, least of all from members of the health care community.' From this quote it is safe to say that the physician has a fiduciary responsibility toward the care of the HIV infected patient and there is no room within the profession for prejudice for people with AIDS. This stand on prejudice should cover not only gay men with AIDS, but also all other patients that a physician takes care of.

1. Richard
2. Roman cath parents- son gay difficult to accept.
Richard must have been prepared for this event- common in gay community.
3. Nurses/paramedical staff experienced in dealing with gay patients and their significant other.
4. For step3- don't have prejudice against gays etc etc./ if you feel uncomfortable to remove from life-support- your personal views are against it- you can depute other attendings.