The prevalence of type 2 diabetes mellitus (DM2) in Spain is 13.8%,1 and patients with diabetes have a higher probability of being hospitalized due to the comorbidities associated with the disease.2 This justifies the elevated prevalence of diabetes in hospitalized patients, which is more than 50% in patients hospitalized for coronary revascularization.3 Moreover, hyperglycemia during hospitalization is associated with poorer prognosis, longer hospitalizations and increased costs.4–8 Nonetheless, hospital discharge is a highly important event in patient care. It involves transferring the responsibility for treatment back to the patient, and generally the Primary Care Physician, and it is a period that is vulnerable to treatment discontinuity and possible adverse drug events.9–12 Randomized observational studies indicate that the control of hyperglycemia can reduce complications during hospitalization in medical and surgical areas,11,13,14 and that the strategies to organize hypoglycemic medication at discharge will improve post-discharge glycemic control.15–17 Therefore, it is important to prevent and treat hyperglycemia during hospitalization and to adjust the medication prescribed at discharge with what the patient was using before admittance.

There are currently guidelines and consensuses for the treatment of hyperglycemia in non-critical hospitalized patients7,11,18,19 that recommend avoiding oral diabetic agents and using standardized protocols with insulin regimens that contemplate baseline, nutritional and correction components. However, although there are data to indicate that these programs are safe and effective,14,17,20–23 there is very limited information about their implementation in practice during hospitalization and especially the adaptation of treatment at discharge.

At our hospital, the Endocrinology Department is responsible for the treatment of patients with diabetes hospitalized in the Vascular Surgery ward. This circumstance has enabled us to apply a hyperglycemia management protocol by expert staff in diabetes management, which is a unique opportunity to determine the characteristics and effectiveness of these programs in conditions of optimal use. Therefore, the objectives of the present study are: (1) to determine the characteristics of the insulin regimens used during the hospitalization of patients in the Vascular Surgery Ward, as well as any modifications in treatment upon discharge taking into account the personal and socio-familial characteristics of the patient and his/her diabetes; and (2) to evaluate the efficacy and safety of the program.

We conducted a retrospective observational study that consecutively included patients with DM admitted to the Vascular Surgery Ward from April 2011 to March 2012. For the analysis, patients with type 1 diabetes were excluded. The study was approved by the hospital Ethics Committee and was performed in accordance with rules for proper clinical practice.

Procedures During Hospitalization

At our hospital, the Endocrinology team monitors patients who are hospitalized daily in the Vascular Surgery unit and have previously or newly diagnosed diabetes (glycosylated hemoglobin [HbA1c] greater or equal to 6.5%).

For all patients, at the time of admittance we requested HbA1c and established the treatment regimen within the first 24h in accordance with the protocol of our institution, which is based on the Spanish Consensus for the management of hyperglycemia in hospital19 (Fig. 1). The selection of the insulin regimen (correctional, basal plus correction, or basal-bolus-correction [BBC]) was made on an individual basis, following the protocol that contemplated the patient's previous treatment, glycemic profile within the first 24h, clinical situation and nutrition. The diet was calculated according to the caloric needs of patients and distributed in 3 daily doses, except in those patients who followed treatment with NPH insulin in 2 doses, in which case the diet was distributed in 5 daily meals.

Fig. 1.

Treatment algorithm for hyperglycemia during hospitalization at the Hospital de la Santa Creu i Sant Pau. DM: diabetes mellitus; TDD: total daily dose; OHA: oral hypoglycemic agents. Source: Adapted from Pérez et al.19

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A minimum of 4 capillary blood glucose tests were done per day (pre-prandial and at 12 am) with Accu-Chek Aviva® glucometer (Roche, F. Hoffmann-La Roche, Basel, Switzerland). Glycemic profiles were reviewed daily, and adjustments were made to treatment to reach and maintain pre-prandial plasma glucose levels between 100 and 140mg/dL.

In this retrospective observational study, we have evaluated the hyperglycemia management protocol based on basal-bolus regimens and conciliation of the treatment at discharge, applied by experts in diabetes management. The study offers new information about the characteristics of the insulin therapies used during hospitalization and the adjustments to treatment upon discharge used in daily clinical practice. The study also confirms the efficacy and safety of the regimens used during hospitalization and modifications made at discharge, considering characteristics of the patients and of their diabetes. We believe that the information provided can contribute to facilitating the implementation of hyperglycemia management protocols in hospitalized patients.

The study was carried out in the Vascular Surgery Ward at our hospital. As expected, and due to the reason for admittance, the patients were older in age and had diseases that had been progressing for a long period. They also presented a high rate of chronic complications and cardiovascular risk factors, which explains the high percentage of patients treated with insulin prior to admittance. Direct supervision by an endocrinologist has meant that the hyperglycemia management protocol of our hospital has been applied by experts in diabetes management, patients with individual characteristics and complex diabetes.

Although different consensuses and recommendations7,11,18,19 establish similar strategies for the selection of the different subtypes of basal-bolus regimens (BBC, basal-correction and only correctional) according to prior treatment and glycemia upon hospitalization, to our knowledge there is no information about the proportion of patients who require the different subtypes of basal-bolus insulin during hospitalization. In general, the studies available refer to the proportion of patients in whom the basal-bolus regimen is established, with no consideration given to the subtypes.24,25

In the present study, in 96.4% of hospitalized patients with hyperglycemia, the insulin regimen was applied following the recommendations of the established protocol (Fig. 1). In 50% of the patients, insulin therapy was used with all the components (BBC), in 23.6% the regimen included the basal plus correction component, and in 22.8% only the correctional component. In accordance with the strategy established for the choice of regimen, the patients treated with the 3 components, compared to those treated with the basal plus correction component or only correction, received more complex treatment (≥2 doses of insulin) before admittance, had poorer glycemic control and hospitalizations were longer. One factor that probably contributed to a greater use of the basal plus correction regimen is the expected lower intake of nutrients common in patients hospitalized for surgical processes, which obviously reduces the prandial component.11 In 3.6% of patients, the previous regimen of the patient was maintained with 2 doses of NPH insulin, and the most relevant characteristic was the short duration of the hospitalization.

Overall, the mean glycemias obtained mid-hospitalization and the last day of hospitalization were significantly lower compared to those from the first day of hospitalization, with a low rate of severe hypoglycemia. However, the improvement was exclusively at the expense of the subgroup of patients treated with the BBC insulin regimen and whose mean glycemia the first day of hospitalization was 184.4±59.2mg/dL, while in the remaining patients the mean glycemia the first day was 140.5±31.4mg/dL and was not modified during hospitalization. These findings confirm the results of previous studies14,20,21,23,26 that demonstrate the efficacy of treatment strategies based on BBC to reach and maintain adequate control in non-critical hospitalized patients. Furthermore, the results of this study show that, in clinical practice, an important percentage of hospitalized patients with type 2 diabetes do not require complete BBC. In 46% of the patients, adequate control is maintained by using basal plus correction or correctional-only components, and the strategy utilized is able to identify these patients. There were no differences in the rate of severe hypoglycemia between the BBC group and the remaining regimens, which demonstrates the adequate indication and safety of BBC during hospitalization. Nonetheless, the rate of mild hypoglycemia was elevated and is probably explained by the definition used, which includes all glycemias <70mg/dL, and the context of a hospital surgery ward, where there are often unanticipated changes in nutrition, changes in medication and presence of comorbidities, such as deteriorated renal function.

Hospital discharge is a situation of risk for patients with diabetes. It is the main risk predictor for severe hypoglycemia in seniors,27 and the presence of diabetes increases by 2.6 times the risk for readmittance due to adverse drug reactions.28 However, the transition in diabetes care at discharge receives little attention, and previous studies have demonstrated that it is clearly an underestimated area12 in which the suppression of previous hypoglycemic medication, therapeutic inertia and the lack of post-discharge follow-up are frequent.29,30 Although the relevance of planning hospital discharge is widely accepted31 and specific recommendations have been established,12,19 information about its effectiveness is very limited.15,17 In the present study, excluding the changes in insulin dose without modification of the regimen, the hypoglycemic treatment at discharge was modified in 22.7% of patients. The most frequent modification was increased dosage or the addition of a non-insulin drug and insulinization with the addition of basal insulin or basal-bolus therapy in patients who were transferred to skilled nursing facilities. In the subgroup of patients for whom we had post-discharge information available, the treatment modifications at discharge were maintained in most patients and glycemic control improved, which reinforces the efficacy of this intervention.

The study presents the limitations inherent of an observational design and retrospective data collection; furthermore, we did not have follow-up data for all patients after discharge. However, the study offers information about the application of hyperglycemia management protocols during hospitalization and at discharge under conditions of standard clinical practice in patients hospitalized for surgery and contributes to the comprehension of this area. Due to the patient characteristics, we consider that the information obtained can be applicable to the majority of hospitalized patients, but especially to surgical patients.

• 1.

  Caimari F: study design, acquisition and data collection, analysis and interpretation of the results, composition of the article, critical review and approval of the final version.

• 2.

  González C: study design, analysis and interpretation off the results, article composition, critical review and approval of the final version.

• 3.

  Ramos A: study design, data collection and acquisition, analysis and interpretation of the results, critical review and approval of the final version.

• 4.

  Chico A: composition of the article, critical review and approval of the final version.

• 5.

  Cubero J.M: data acquisition and collection, critical review and approval of the final version.

• 6.

  Pérez A: study design, analysis and interpretation of the results, composition of the article, critical review and approval of the final version.

The authors have no conflicts to declare related with the content of the manuscript.