Skip to main content

02-14-2018 | Inpatient diabetes | Review | Article

Common Models Used for Inpatient Diabetes Management

Journal: Current Diabetes Reports

Authors: Andjela T. Drincic, Padmaja Akkireddy, Jon T. Knezevich

Publisher: Springer US


Purpose of Review

Diabetes affects about a third of all hospitalized patients and up to 50% of inpatients go on to experience hyperglycemia. Despite strong evidence supporting the importance of adequate glycemic control, as well detailed guidelines from major national organizations, many patients continue to have hypo- and hyperglycemia during their hospital stay. While this may be partially related to provider and patient-specific factors, system-based barriers continue to pose a major obstacle. Therefore, there is a need to go beyond merely discussing specific insulin protocols and provide guidance for effective models of care in the acute glycemic management of hospitalized patients.

Recent Findings

To date, there is limited data evaluating the various models of care for inpatient diabetes management in terms of efficacy or cost, and there is no summary on this topic guiding physicians and hospital administrators.


In this paper, four common models of inpatient diabetes care will be presented including those models led by the following: an endocrinologist(s), mid-level provider(s), pharmacist(s), and a virtual glucose management team. The authors will outline the intrinsic benefits as well as limitations of each model of care as well as cite supporting evidence, when available. Discussion pertaining to how a given model of care shapes and formulates a particular organization’s structured glucose management program (GMP) will be examined. Furthermore, the authors describe how the model of care chosen by an institution serves as the foundation for the creation of a GMP. Finally, the authors examine the critical factors needed for GMP success within an institution and outline the nature of hospital administrative support and accompanying reporting structure, the function of a multidisciplinary diabetes steering committee, and the role of the medical director.
Herman WH, Zimmet P. Type 2 diabetes: an epidemic requiring global attention and urgent action. Diabetes Care. 2012;35(5):943–4.
Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2017. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept of Health and Human Services; 2017.
Donnan PT, Leese GP, Morris AD, Diabetes A, Research in Tayside SMMUC. Hospitalizations for people with type 1 and type 2 diabetes compared with the nondiabetic population of Tayside, Scotland: a retrospective cohort study of resource use. Diabetes Care. 2000;23(12):1774–9. https://​doi.​org/​10.​2337/​diacare.​23.​12.​1774. CrossRefPubMed
Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab. 2002;87(3):978–82. https://​doi.​org/​10.​1210/​jcem.​87.​3.​8341. CrossRefPubMed
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. https://​doi.​org/​10.​1210/​jc.​2011-2098. CrossRefPubMed
ADA standards of care 2017. Diabetes Care 2017 Jan ; 40 (Supplement 1).
Draznin B, Gilden J, Golden SH, Inzucchi SE, investigators P, Baldwin D, et al. Pathways to quality inpatient management of hyperglycemia and diabetes: a call to action. Diabetes Care. 2013;36(7):1807–14. https://​doi.​org/​10.​2337/​dc12-2508. CrossRefPubMedPubMedCentral
Levetan CS, Salas JR, Wilets IF, Zumoff B. Impact of endocrine and diabetes team consultation on hospital length of stay for patients with diabetes. Am J Med. 1995;99(1):22–8. https://​doi.​org/​10.​1016/​S0002-9343(99)80100-4. CrossRefPubMed
Newton CA, Young S. Financial implications of glycemic control: results of an inpatient diabetes management program. Endocr Pract. 2006;12(Suppl 3):43–8. https://​doi.​org/​10.​4158/​EP.​12.​S3.​43. CrossRefPubMed
Koproski J, Pretto Z, Poretsky L. Effects of an intervention by a diabetes team in hospitalized patients with diabetes. Diabetes Care. 1997;20(10):1553–5. https://​doi.​org/​10.​2337/​diacare.​20.​10.​1553. CrossRefPubMed
Puig J, Supervia A, Marquez MA, Flores J, Cano JF, Gutierrez J. Diabetes team consultation: impact on length of stay of diabetic patients admitted to a short-stay unit. Diabetes Res Clin Pract. 2007;78(2):211–6. https://​doi.​org/​10.​1016/​j.​diabres.​2007.​03.​010. CrossRefPubMed
• Rajendran R, Round RM, Kerry C, Barker S, Rayman G. Diabetes patient at risk score—a novel system for triaging appropriate referrals of inpatients with diabetes to the diabetes team. Clin Med (Lond). 2015;15(3):229–33. This study provides a scoring system to identify patients who would beneft from diabetes team consultation. https://​doi.​org/​10.​7861/​clinmedicine.​15-3-229. CrossRef
Korytkowski M, Dinardo M, Donihi AC, Bigi L, Devita M. Evolution of a diabetes inpatient safety committee. Endocr Pract. 2006;12(Suppl 3):91–9. https://​doi.​org/​10.​4158/​EP.​12.​S3.​91. CrossRefPubMed
Pietras SM, Hanrahan P, Arnold LM, Sternthal E, McDonnell ME. State-of-the-art inpatient diabetes care: the evolution of an academic hospital. Endocr Pract. 2010;16(3):512–21. https://​doi.​org/​10.​4158/​EP09319.​CO.
Munoz M, Pronovost P, Dintzis J, Kemmerer T, Wang NY, Chang YT, et al. Implementing and evaluating a multicomponent inpatient diabetes management program: putting research into practice. Jt Comm J Qual Patient Saf. 2012;38(5):195–206. https://​doi.​org/​10.​1016/​S1553-7250(12)38025-2. CrossRefPubMedPubMedCentral
Olson L, Muchmore J, Lawrence CB. The benefits of inpatient diabetes care: improving quality of care and the bottom line. Endocr Pract. 2006;12(Suppl 3):35–42. https://​doi.​org/​10.​4158/​EP.​12.​S3.​35. CrossRefPubMed
• Rushakoff RJ, Sullivan MM, MacMaster HW, 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. Recent study evaluating the effect of remote monitoring on glycemic control. https://​doi.​org/​10.​7326/​M16-1413. CrossRefPubMed
Mendez CE, Ata A, Rourke JM, Stain SC, Umpierrez G. Daily inpatient glycemic survey (Dings): a process to remotely identify and assist in the management of hospitalized patients with diabetes and hyperglycemia. Endocr Pract. 2015;21(8):927–35. https://​doi.​org/​10.​4158/​EP14577.​OR. CrossRefPubMed
Johansson T, Wild C. Telemedicine in acute stroke management: systematic review. Int J Technol Assess Health Care. 2010;26(2):149–55. https://​doi.​org/​10.​1017/​S026646231000013​9. CrossRefPubMed
Shea S, Weinstock RS, Teresi JA, Palmas W, Starren J, Cimino JJ, et al. A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus: 5 year results of the IDEATel study. J Am Med Inform Assoc. 2009;16(4):446–56. https://​doi.​org/​10.​1197/​jamia.​M3157. 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. https://​doi.​org/​10.​4158/​EP14367.​OR. CrossRefPubMed
Cheekati V, Osburne RC, Jameson KA, Cook CB. Perceptions of resident physicians about management of inpatient hyperglycemia in an urban hospital. J Hosp Med. 2009;4(1):E1–8. https://​doi.​org/​10.​1002/​jhm.​383. CrossRefPubMed
Cook CB, McNaughton DA, Braddy CM, Jameson KA, Roust LR, Smith SA, et al. Management of inpatient hyperglycemia: assessing perceptions and barriers to care among resident physicians. Endocr Pract. 2007;13(2):117–24. https://​doi.​org/​10.​4158/​EP.​13.​2.​117. CrossRefPubMed
Tamler R, Green DE, Skamagas M, Breen TL, Looker HC, Babyatsky M, et al. Effect of case-based training for medical residents on inpatient glycemia. Diabetes Care. 2011;34(8):1738–40. https://​doi.​org/​10.​2337/​dc11-0517. CrossRefPubMedPubMedCentral
Vaidya A, Hurwitz S, Yialamas M, Min L, Garg R. Improving the management of diabetes in hospitalized patients: the results of a computer-based house staff training program. Diabetes Technol Ther. 2012;14(7):610–8. https://​doi.​org/​10.​1089/​dia.​2011.​0258. CrossRefPubMedPubMedCentral
Desimone ME, Blank GE, Virji M, Donihi A, DiNardo M, Simak DM, et al. Effect of an educational Inpatient Diabetes Management Program on medical resident knowledge and measures of glycemic control: a randomized controlled trial. Endocr Pract. 2012;18(2):238–49. https://​doi.​org/​10.​4158/​EP11277.​OR. CrossRefPubMed
Wallia A, Gupta S, Garcia C, Schmidt K, Oakes DJ, Aleppo G, et al. Examination of implementation of intravenous and subcutaneous insulin protocols and glycemic control in heart transplant patients. Endocr Pract. 2014;20(6):527–35. https://​doi.​org/​10.​4158/​EP13354.​OR. CrossRefPubMed
• Mackey PA, Boyle ME, Walo PM, Castro JC, Cheng MR, Cook CB. Care directed by a specialty-trained nurse practioner or physician assistant can overcome clinical inertia in management of inpatient diabetes. Endocr Pract. 2014;20(2):112–9. This study evaluated a model led by cross trained mid level providers in inpatient diabetes management. https://​doi.​org/​10.​4158/​EP13201.​OR. CrossRefPubMed
Apsey HA, Coan KE, Castro JC, Jameson KA, Schlinkert RT, Cook CB. Overcoming clinical inertia in the management of postoperative patients with diabetes. Endocr Pract. 2014;20(4):320–8. https://​doi.​org/​10.​4158/​EP13366.​OR. CrossRefPubMed
Donihi AC, Gibson JM, Noschese ML, DiNardo MM, Koerbel GL, Curll M, et al. Effect of a targeted glycemic management program on provider response to inpatient hyperglycemia. Endocr Pract. 2011;17(4):552–7. https://​doi.​org/​10.​4158/​EP10330.​OR. CrossRefPubMed
Warrington L, Ayers P, Baldwin AM, Wallace V, Riche KD, Saulters R, et al. Implementation of a pharmacist-led, multidisciplinary diabetes management team. Am J Health Syst Pharm. 2012;69(14):1240–5. https://​doi.​org/​10.​2146/​ajhp110297. CrossRefPubMed
• Mularski KS, Yeh CP, Bains JK, Mosen DM, Hill AK, Mularski RA. Pharmacist glycemic control team improves quality of glycemic control in surgical patients with perioperative dysglycemia. Perm J. 2012;16(1):28–33. This study evaluated how a pharmacist-led model of care impacted postoperative glycemic outcomes in surgical patients. CrossRefPubMedPubMedCentral
Hodges A, Hall J, Castellanos E, Laue E, Ellis T, Oelschlaeger L. Implementing a pharmacist consultation model for multimodal insulin therapy. Am J Health Syst Pharm. 2017;74(9):e224–9. https://​doi.​org/​10.​2146/​ajhp150941. CrossRefPubMed
Joint Commission Perspectives®, July 2016. 36(7):1–8.
Heyerly A, Jones R, Bokhart G, Shoaff M, Fisher D. Implementation of a pharmacist-direct antimicrobial stewardship protocol utilizing rapid diagnostic testing. Hosp Pharm. 2016;51(10):815–22. https://​doi.​org/​10.​1310/​hpj5110-815. CrossRefPubMedPubMedCentral
Wenzler E, Wang F, Goff DA, Prier B, Mellett J, Mangino JE, et al. An automated, pharmacist-driven initiative improves quality of care for Staphylococcus aureus bacteremia. Clin Infect Dis. 2017;65(2):194–200. https://​doi.​org/​10.​1093/​cid/​cix315. CrossRefPubMed
Zhang X, Rowan N, Pflugeisen BM, Alajbegovic S. Urine culture guided antibiotic interventions: a pharmacist driven antimircrobial stewardship effort in the ED. Am J Emerg Med. 2017;35(4):594–8. https://​doi.​org/​10.​1016/​j.​ajem.​2016.​12.​036. CrossRefPubMed
Heil EL, Kuti JL, Bearden DT, Gallagher JC. The essential role of pharmacists in antimicrobial stewardship. Infect Control Hosp Epidemiol. 2016;37(7):753–4. https://​doi.​org/​10.​1017/​ice.​2016.​82. CrossRefPubMed
Paterson DL. The role of antimicrobial management programs in optimizing antibiotic prescribing within hospitals. Clin Infect Dis. 2006;42(2):S90–5. https://​doi.​org/​10.​1086/​499407. CrossRefPubMed
Golmann A, Yokoe S. Approaches for preventing healthcare-associated infections: go long or go wide? Infect Control Hosp Epidemiol. 2014;35(7):797–801. CrossRef
Rushakoff RJ, Rushakoff JA, Kornberg Z, MacMaster HW, Shah AD. Remote monitoring and consultation of inpatient populations with diabetes. Curr Diab Rep. 2017;17(9):70. https://​doi.​org/​10.​1007/​s11892-017-0896-x. CrossRefPubMed
Schnipper JL, Liang CL, Ndumele CD, Pendergrass ML. Effects of a computerized order set on the inpatient management of hyperglycemia: a cluster-randomized controlled trial. Endocr Pract. 2010;16(2):209–18. https://​doi.​org/​10.​4158/​EP09262.​OR. CrossRefPubMed
Espina C, Jenkins I, Taylor L, Farah R, Cho E, Epworth J, et al. Blood glucose control using a computer-guided glucose management system in allogeneic hematopoietic cell transplant recipients. Bone Marrow Transplant. 2016;51(7):973–9. https://​doi.​org/​10.​1038/​bmt.​2016.​78. CrossRefPubMed
American College of Endocrinology and American Diabetes Association Consensus statement on inpatient diabetes and glycemic control. Diabetes Care. 2006;29(8):1955–62.
Drincic A, Pfeffer E, Luo J, Goldner WS. The effect of diabetes case management and diabetes resource nurse program on readmissions of patients with diabetes mellitus. J Clin Transl Endocrinol. 2017;8:29–34. https://​doi.​org/​10.​1016/​j.​jcte.​2017.​03.​003. CrossRefPubMedPubMedCentral
Mathioudakis N, Pronovost PJ, Cosgrove SE, Hager D, Golden SH. Modeling inpatient glucose management programs on hospital infection control programs: an infrastructural model of excellence. Jt Comm J Qual Patient Saf. 2015;41(7):325–36. https://​doi.​org/​10.​1016/​S1553-7250(15)41043-8. CrossRefPubMedPubMedCentral