Skip to main content

10-05-2017 | Hypoglycemia | Review | Article

A Systematic Approach for the Prevention and Reduction of Hypoglycemia in Hospitalized Patients

Journal: Current Diabetes Reports

Authors: Paulina Cruz, Mary Clare Blackburn, Garry S. Tobin

Publisher: Springer US



Purpose of Review

Hypoglycemia and severe hypoglycemia (SH) in the inpatient setting are associated with poor outcomes. This review is designed to highlight approaches to predict and prevent inpatient hypoglycemia that has been successfully implemented focusing on developing overlapping policies and procedures that allow safe glycemic management to occur at all levels of the institution.

Recent Findings

Standardizing point-of-care (POC) testing, nursing protocols, meal delivery, and formulary restriction are useful tools to prevent hypoglycemia. Informatics and real-time alert processes are highly effective tools to reduce hypoglycemia but require a significant investment in time and infrastructure as well as clear policies on how alerts are acted upon. Computerized dosing support technology and continuous glucose monitoring (CGM) technology are an emerging area of investigation showing promising results.


Inpatient hypoglycemia is often predictable and preventable and requires institutional support to deliver targeted and safe diabetes care. This requires each institution to do periodic reassessment of policies and technologies. Future research needs to focus on the cost/benefits of interventions including studies of automated dosing algorithms as well as CGM in higher-risk patient populations.
Carey M, Boucai L, Zonszein J. Impact of hypoglycemia in hospitalized patients. Curr Diab Rep. 2013;13(1):107–13. CrossRefPubMed
Akirov A, Grossman A, Shochat T, Shimon I. Mortality among hospitalized patients with hypoglycemia: insulin related and noninsulin related. J Clin Endocrinol Metab. 2017;102(2):416–24. PubMed
Garg R, Hurwitz S, Turchin A, Trivedi A. Hypoglycemia, with or without insulin therapy, is associated with increased mortality among hospitalized patients. Diabetes Care. 2013;36(5):1107–10. CrossRefPubMedPubMedCentral
Turchin A, Matheny ME, Shubina M, Scanlon JV, Greenwood B, Pendergrass ML. Hypoglycemia and clinical outcomes in patients with diabetes hospitalized in the general ward. Diabetes Care. 2009;32(7):1153–7. CrossRefPubMedPubMedCentral
Maynard G, Kulasa K, Ramos P, Childers D, Clay B, Sebasky M, et al. Impact of a hypoglycemia reduction bundle and a systems approach to inpatient glycemic management. Endocr Pract. 2015;21(4):355–67. CrossRefPubMed
Cryer PE. Hypoglycemia, functional brain failure, and brain death. J Clin Invest. 2007;117(4):868–70. CrossRefPubMedPubMedCentral
Schwartz NS, Clutter WE, Shah SD, Cryer PE. Glycemic thresholds for activation of glucose counterregulatory systems are higher than the threshold for symptoms. J Clin Invest. 1987;79(3):777–81. CrossRefPubMedPubMedCentral
Thomas M, Sherwin RS, Murphy J, Kerr D. Importance of cerebral blood flow to the recognition of and physiological responses to hypoglycemia. Diabetes. 1997;46(5):829–33. CrossRefPubMed
Standards of medical care in diabetes—2017: summary of revisions. Diabetes care. 2017;40(Suppl 1):S4–S5.
Umpierrez GE, Hellman R, Korytkowski MT, Kosiborod M, Maynard GA, Montori VM, et al. Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2012;97(1):16–38. CrossRefPubMed
Bersoux S, Cook CB, Kongable GL, Shu J, Zito DR. Benchmarking glycemic control in U.S. hospitals. Endocr Pract. 2014;20(9):876–83. CrossRefPubMed
Brodovicz KG, Mehta V, Zhang Q, Zhao C, Davies MJ, Chen J, et al. Association between hypoglycemia and inpatient mortality and length of hospital stay in hospitalized, insulin-treated patients. Curr Med Res Opin. 2013;29(2):101–7. CrossRefPubMed
Gomez AM, Umpierrez GE, Munoz OM, Herrera F, Rubio C, Aschner P, et al. Continuous glucose monitoring versus capillary point-of-care testing for inpatient glycemic control in type 2 diabetes patients hospitalized in the general ward and treated with a basal bolus insulin regimen. J Diabetes Sci Technol. 2015;10(2):325–9. CrossRefPubMedPubMedCentral
Rubin DJ, Golden SH. Hypoglycemia in non-critically ill, hospitalized patients with diabetes: evaluation, prevention, and management. Hosp Pract. 2013;41(1):109–16. CrossRef
Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011;365(21):2002–12. CrossRefPubMed
Federico F. Preventing harm from high-alert medications. Jt Comm J Qual Patient safety. 2007;33(9):537–42. CrossRef
Deal EN, Liu A, Wise LL, Honick KA, Tobin GS. Inpatient insulin orders: are patients getting what is prescribed? J Hosp Med. 2011;6(9):526–9. CrossRefPubMed
Sinha Gregory N, Seley JJ, Gerber LM, Tang C, Brillon D. Decreased rates of hypoglycemia following implementation of a comprehensive computerized insulin order set and titration algorithm in the inpatient setting. Hosp Pract. 2016;44(5):260–5. CrossRef
Moghissi ES, Korytkowski MT, DiNardo M, Einhorn D, Hellman R, Hirsch IB, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care. 2009;32(6):1119–31. CrossRefPubMedPubMedCentral
Engle M, Ferguson A, Fields W. A journey to improved inpatient glycemic control by redesigning meal delivery and insulin administration. Clin Nurse Spec CNS. 2016;30(2):117–24. CrossRefPubMed
•• Milligan PE, Bocox MC, Pratt E, Hoehner CM, Krettek JE, Dunagan WC. Multifaceted approach to reducing occurrence of severe hypoglycemia in a large healthcare system. Am J Health Syst Pharm. 2015;72(19):1631–41. This study reports the results of implementing glucometric measurements, standardized order sets and policies as well as best practices for diabetes care in 13 hospitals. It is an excellent example of a relatively low cost targeted intervetion and shows the additional value one achieves with implementing a predictive alert for hypoglycemia. CrossRefPubMed
Jones GC, Casey H, Perry CG, Kennon B, Sainsbury CA. Trends in recorded capillary blood glucose and hypoglycaemia in hospitalised patients with diabetes. Diabetes Res Clin Pract. 2014;104(1):79–83. CrossRefPubMed
Lee YY, Lin YM, Leu WJ, Wu MY, Tseng JH, Hsu MT, et al. Sliding-scale insulin used for blood glucose control: a meta-analysis of randomized controlled trials. Metab Clin Exp. 2015;64(9):1183–92. CrossRefPubMed
Elliott MB, Schafers SJ, McGill JB, Tobin GS. Prediction and prevention of treatment-related inpatient hypoglycemia. J Diabetes Sci Technol. 2012;6(2):302–9. CrossRefPubMedPubMedCentral
Rajendran R, Rayman G. Serious harm from inpatient hypoglycaemia: a survey of hospitals in the UK. Diabet Med. 2014;31(10):1218–21. CrossRefPubMed
Schafers S, Naunheim R, Vijayan A, Tobin G. Incidence of hypoglycemia following insulin-based acute stabilization of hyperkalemia treatment. J Hosp Med. 2012;7(3):239–42. CrossRefPubMed
Coca A, Valencia AL, Bustamante J, Mendiluce A, Floege J. Hypoglycemia following intravenous insulin plus glucose for hyperkalemia in patients with impaired renal function. PLoS One. 2017;12(2):e0172961. CrossRefPubMedPubMedCentral
Wheeler DT, Schafers SJ, Horwedel TA, Deal EN, Tobin GS. Weight-based insulin dosing for acute hyperkalemia results in less hypoglycemia. J Hosp Med. 2016;11(5):355–7. CrossRefPubMed
Deusenberry CM, Coley KC, Korytkowski MT, Donihi AC. Hypoglycemia in hospitalized patients treated with sulfonylureas. Pharmacotherapy. 2012;32(7):613–7. CrossRefPubMed
Lipska KJ, Ross JS, Wang Y, Inzucchi SE, Minges K, Karter AJ, et al. National trends in US hospital admissions for hyperglycemia and hypoglycemia among Medicare beneficiaries, 1999 to 2011. JAMA Intern Med. 2014;174(7):1116–24. CrossRefPubMedPubMedCentral
Umpierrez GE, Smiley D, Hermayer K, Khan A, Olson DE, Newton C, et al. Randomized study comparing a basal-bolus with a basal plus correction insulin regimen for the hospital management of medical and surgical patients with type 2 diabetes: basal plus trial. Diabetes Care. 2013;36(8):2169–74. CrossRefPubMedPubMedCentral
Umpierrez GE, Smiley D, Zisman A, Prieto LM, Palacio A, Ceron M, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial). Diabetes Care. 2007;30(9):2181–6. CrossRefPubMed
Umpierrez GE. Inpatient management of diabetes: an increasing challenge to the hospitalist physician. J Hosp Med. 2007;2(Suppl 1):33–5. CrossRefPubMed
Pasquel FJ, Gianchandani R, Rubin DJ, Dungan KM, Anzola I, Gomez PC, et al. Efficacy of sitagliptin for the hospital management of general medicine and surgery patients with type 2 diabetes (Sita-Hospital): a multicentre, prospective, open-label, non-inferiority randomised trial. Lancet Diabetes Endocrinol. 2017;5(2):125–33. CrossRefPubMed
•• Aloi J, Bode BW, Ullal J, Chidester P, RS MF, Bedingfield AE, et al. Comparison of an electronic glycemic management system versus provider-managed subcutaneous basal bolus insulin therapy in the hospital setting. J Diabetes Sci Technol. 2017;11(1):12–6. This study was a crossover multicenter study looking at 999 non ICU patients comparing electronic glycemic management (EGM) versus provider directed basal bolus therapy. The study showed that the EGM group achieved improved glycemic control with lower incidence of hypoglycemia (<40 mg/dL and <70 mg/dl) compared to basal bolus treatment managed by a provider. CrossRefPubMed
Baldwin D, Zander J, Munoz C, Raghu P, DeLange-Hudec S, Lee H, et al. A randomized trial of two weight-based doses of insulin glargine and glulisine in hospitalized subjects with type 2 diabetes and renal insufficiency. Diabetes Care. 2012;35(10):1970–4. CrossRefPubMedPubMedCentral
Lee SY, Askin G, McDonnell ME, Arnold LM, Alexanian SM. Hypoglycemia rates after restriction of high-dose glargine in hospitalized patients. Endocr Pract. 2016;22(12):1393–400. CrossRefPubMed
•• Maynard GA, Childers D, Holdych J, Kendall H, Hoag T, Harrison K. Improving glycemic control safely in non-critical care patients: a collaborative systems approach in nine hospitals. Jt Comm J Qual Patient Saf. 2017;43(4):179–88. This study reports the results of implementing glucometric measurements, standardized order sets and policies as well as best practices for diabetes care in 9 hospitals. It is an excellent example of a relatively low cost targeted intervetion. CrossRefPubMed
Bellido V, Suarez L, Rodriguez MG, Sanchez C, Dieguez M, Riestra M, et al. Comparison of basal-bolus and premixed insulin regimens in hospitalized patients with type 2 diabetes. Diabetes Care. 2015;38(12):2211–6. CrossRefPubMedPubMedCentral
• Kilpatrick CR, Elliott MB, Pratt E, Schafers SJ, Blackburn MC, Heard K, et al. Prevention of inpatient hypoglycemia with a real-time informatics alert. J Hosp Med. 2014;9(10):621–6. This study was a prospective cohort study showing the value of a predictive hypoglycemia alert in an academic medical center. The alert process resulted in a significant decrease by 68% in the rate of SH in alerted high-risk patients versus nonalerted high-risk patients (3.1% vs 9.7%, P = 0.012). It was subsequently utilized in reference 21 above. CrossRefPubMed
• Rushakoff RJ, Sullivan MM, HW MM, Shah AD, Rajkomar A, Glidden DV, et al. Association between a virtual glucose management service and glycemic control in hospitalized adult patients: an observational study. Ann Intern Med. 2017;166(9):621–7. This study reports the value of a remote intervention and monitoring process targeting patients with persistent hyperglycemia as defined by 2 or more glucose values >12.5 mmol/l (225 mg/dl) or < 3.9 mmol/l ( 70mg/dl) in the last 24 hours. A virtual consult recommendation was placed in the patients electronic medical record after a virtual review of the chart. The recommendations were then reviewed by the patient’s treating providers and could then be implemented. The virtual consult process reduced hypoglycemia and improved the rates of hyperglycemia. CrossRefPubMed
Akirov A, Dicker D, Shochat T, Shimon I. Mortality risk in admitted patients with diabetes mellitus according to treatment. J Diabetes Complicat. 2016;30(6):1025–31. CrossRefPubMed
Lowden E, Schmidt K, Mulla I, Andrei AC, Cashy J, Oakes DJ, et al. Evaluation of outcomes and complications in patients who experience hypoglycemia after cardiac surgery. Endocr Pract. 2017;23(1):46–55. CrossRefPubMed