Glycemic Control in Hospitalized Patients With Diabetes Mellitus: Case Series and Literature Review to Reduce Inpatient Hyperglycemia With or Without Diabetic Ketoacidosis

The importance of inpatient glycemic control is undeniable. According to the American Diabetes Association guidelines, insulin should be initiated or intensified for persistent hyperglycemia, starting when the level reaches more than or equal to 180 mg/dL. For critical patients, the recommended glycemic target is 140 mg/dL to 180 mg/dL.(1) Inpatient hyperglycemia is common, with studies showing that up to 40% of diabetic patients experience glucose levels above 180 mg/dL during admission, and poorly managed blood glucose can lead to diabetic ketoacidosis (DKA), a preventable and severe complication associated with prolonged hospital stays, increased costs, elevated mortality risk, and poor health outcomes.(2,3) This article( )discusses six cases of DKA that developed during admissions to our community hospital over the period from April 2022 to October 2023. These cases were attributed to varied causes, including physiological stress (e.g., infection, surgery), inadequate insulin dosing, delayed recognition of hyperglycemia, and inconsistent monitoring. This review aims to reduce inpatient DKA incidence by suggesting standardized protocols, staff education, and enhanced monitoring to improve patients’ outcomes and establish a sustainable model for glycemic management.

Discussion

Diabetic ketoacidosis results from insulin deficiency, leading to hyperglycemia (>250 mg/dL), ketosis, and acidosis (pH <7.3). Inpatient DKA often is linked to delayed recognition or inadequate treatment of hyperglycemia. The literature supports quality improvement (QI) interventions such as insulin protocols, regular feedback and audits, and educational interventions as effective in reducing DKA rates by up to 57%.(4-6) Our hospital recorded six cases of DKA that could have been prevented:

• Case 1: A 44-year-old woman (A1C 7.2) with diabetes type 1 who was taken off her insulin pump for surgery;

• Case 2: A 76-year-old woman (A1C 10.1) with diabetes type 1 who was refusing medications;

• Case 3: A 77-year-old man (A1C 7.3) with diabetes type 2 who was placed on a NPO diet in preparation for treatment of a nonsurgical left femoral fracture;

• Case 4: An 81-year-old man (A1C 6.1) with diabetes type 2 who was not started on an insulin drip during the postoperative period after a coronary artery bypass graft;

• Case 5: A 45-year-old woman (A1C 7.4) with diabetes type 1 who was placed on a NPO diet because of altered mental status secondary to sepsis; and

• Case 6: An 89-year-old woman (A1C 8.5) with diabetes type 2 with inadequate insulin dosing/stressors.

These cases reveal several common themes: delayed recognition, inadequate monitoring, and inconsistent insulin management.

The literature shows that it is possible to improve care and significantly reduce such events and, consequently, significant complications, including increased mortality, particularly in critically ill patients; a higher risk of infections, including healthcare-associated infections; exacerbation of cardiovascular events such as myocardial infarction and stroke; renal complications such as acute kidney injuries; and prolonged hospital stays, with patients experiencing greater disability after discharge.(7) Some of the interventions include standardized protocols: basal-bolus insulin regimens for persistent hyperglycemia and seamless IV-to-subcutaneous transitions. The common practice of adding only sliding-scale insulin noted in several publications has no benefit in regard to glycemic control with higher rates of hyperglycemia(3); and new technologies using computer-guided insulin dosing software, such as Glucommander (currently in a pilot project at our main hospital), the EndoTool System, and Glucostabilizer electronic glucose management systems have been proven to improve hyperglycemia episodes, showing faster glucose normalization (9.7 vs. 11 hours); prevent hypoglycemia (12.9% vs. 35%); and, consequently, decreasing length of hospital stay especially for high-risk patients (e.g., postsurgical or those in the intensive care unit).(3,7,8) Multidisciplinary team collaboration with nurses, diabetes educators, dieticians, pharmacists, internists, and endocrinologists with continuous education programs, enhances glycemic control and reduces diabetic ketoacidosis incidence in hospitalized patients.(9-11)

Conclusion

Implementing continuous glucose monitoring and standardized glycemic control protocols is essential to prevent delays and mismanagement of hyperglycemia, ultimately reducing the incidence of DKA and improving patient outcomes. The adoption of evidence-based interventions, such as basal-bolus insulin regimens, electronic glucose management systems, and seamless transitions from IV to subcutaneous insulin, can significantly enhance the management of inpatient hyperglycemia. However, challenges such as staff compliance and the associated costs of continuous glucose monitoring technologies may arise. These challenges can be mitigated through strong leadership support, ongoing staff education, and fostering a culture of collaboration among multidisciplinary teams. By addressing these obstacles and ensuring consistent application of standardized protocols, healthcare facilities can improve glycemic control, reduce complications, shorten hospital stays, and enhance overall patient care.

References

1. American Diabetes Association Professional Practice Committee. 16. Diabetes Care in the Hospital: Standards of Care in Diabetes—2025. Diabetes Care. 2024;9;48(Supplement_1):S321-S334. https://doi.org/10.2337/dc25-S016

2. Carvalho RC, Nishi FA, Ribeiro TB, França GG, Aguiar PM. Association between intra-hospital uncontrolled glycemia and health outcomes in patients with diabetes: a systematic review of observational studies. Curr Diabetes Rev. 2021;17:304-316. https://doi.org/10.2174/1573399816666200130093523

3. Newsom R, Patty C, Camarena E, et al. Safely converting an entire academic medical center from sliding scale to basal bolus insulin via implementation of the eGlycemic Management System. J Diabetes Sci Technol. 2018;12(1):53–9. https://doi.org/10.1177/1932296817747619

4. Rao P, Jiang S-F, Kipnis P, Patel DM, Katsnelson S, Madani S, et al. Evaluation of outcomes following hospital-wide implementation of a subcutaneous insulin protocol for diabetic ketoacidosis. JAMA Netw Open. 2022;5(4):e226417. https://doi.org/10.1001/jamanetworkopen.2022.6417

5. Rengarajan LN, Cooper C, Malhotra K, et al. DEKODE—a cloud‐based performance feedback model improved DKA care across multiple hospitals in the UK. Diabet Med. 2025;Feb 17:e70004. https://doi.org/10.1111/dme.70004

6. Kempegowda P, Coombs B, Nightingale P, et al. Regular and frequent feedback of specific clinical criteria delivers a sustained improvement in the management of diabetic ketoacidosis. Clin Med. 2017;17:389-394. https://doi.org/10.7861/clinmedicine.17-5-389

7. Barmanray RD, Kyi M, Worth LJ, et al. Hyperglycemia in hospital: an independent marker of infection, acute kidney injury, and stroke for hospital inpatients. J Clin Endocrinol Metab. 2024;109:e2048-2056. https://doi.org/10.1210/clinem/dgae051

8. Bouldin MG, Hong B, Setji T, et al. Evaluation of the efficacy and safety of an eGlycemic management system in a community hospital setting. J Diabetes Sci Technol. 2021;15:236-241. https://doi.org/10.1177/1932296820980026

9. Ullal J, Aloi JA, Reyes-Umpierrez D, et al. Comparison of computer-guided versus standard insulin infusion regimens in patients with diabetic ketoacidosis. J Diabetes Sci Technol. 2018;12(1):39-46. https://doi.org/10.1177/1932296817750899

10. Chehade JM, Sheikh-Ali M, Alexandraki I, House J, Mooradian AD. The effect of healthcare provider education on diabetes management of hospitalised patients: effect of provider education on in-hospital glycaemic control. Int J Clin Pract. 2010;64:917-924. https://doi.org/10.1111/j.1742-1241.2009.02130.x

11. Munoz M, Pronovost P, Dintzis J, et al. Implementing and evaluating a multicomponent inpatient diabetes management program: putting research into practice. Jt Comm J Qual Patient Saf. 2012;38:195-AP4. https://doi.org/10.1016/S1553-7250(12)38025-2