Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association.

Diabetes is more common in older adults, has a high prevalence in long-term care (LTC) facilities, and is associated with significant disease burden and higher cost. The heterogeneity of this population with regard to comorbidities and overall health status is critical to establishing personalized goals and treatments for diabetes. The risk of hypoglycemia is the most important factor in determining glycemic goals due to the catastrophic consequences in this population. Simplified treatment regimens are preferred, and the sole use of sliding scale insulin (SSI) should be avoided. This position statement provides a classification system for older adults in LTC settings, describes how diabetes goals and management should be tailored based on comorbidities, delineates key issues to consider when using glucose-lowering agents in this population, and provides recommendations on how to replace SSI in LTC facilities. As these patients transition from one setting to another, or from one provider to another, their risk for adverse events increases. Strategies are presented to reduce these risks and ensure safe transitions. This article addresses diabetes management at end of life and in those receiving palliative and hospice care. The integration of diabetes management into LTC facilities is important and requires an interprofessional team approach. To facilitate this approach, acceptance by administrative personnel is needed, as are protocols and possibly system changes. It is important for clinicians to understand the characteristics, challenges, and barriers related to the older population living in LTC facilities as well as the proper functioning of the facilities themselves. Once these challenges are identified, individualized approaches can be designed to improve diabetes management while lowering the risk of hypoglycemia and ultimately improving quality of life.

The Mealtime Challenge: Nutrition and Glycemic Control in the Hospital.

In Brief Multiple staff members and departments have a responsibility for various aspects of nutrition therapy for glycemic management in the hospital setting. Implementation is initiated by physicians, nurse practitioners, and physician's assistants and planned and operationalized by registered dietitians. Meals are delivered by food service staff, and nurses monitor and integrate glycemic control components into patients' medical treatment plan. Although nutrition therapy is recognized as an important aspect of care in the hospital setting, it can also be challenging to appropriately coordinate meals with blood glucose monitoring and insulin administration. This article addresses current mealtime practices and recommendations to improve these processes in acute care.

Inpatient management of diabetes and hyperglycemia: implications for nutrition practice and the food and nutrition professional.

Although numerous guidelines and standards address the management of diabetes in outpatient settings, only recently has evidence been provided to issue standards of care to guide clinicians in optimal inpatient glycemic control for hospitalized individuals with diabetes or illness-induced hyperglycemia. Both the American Diabetes Association and the American College of Endocrinology recommend critically ill patients keep their blood glucose level as close to 110 mg/dL (6.1 mmol/L) as possible. In the noncritically ill patient, the American Diabetes Association recommends to keep pre-meal blood glucose as close to 90 to 130 mg/dL (5.0 to 7.2 mmol/L) as possible, whereas the American College of Endocrinology recommends pre-meal blood glucose be kept at 110 mg/dL (6.1 mmol/L) or less. Both organizations agree that peak post-prandial blood glucose should be 180 mg/dL (10.0 mmol/L) or less. Recent evidence has also led the Joint Commission on Accreditation of Healthcare Organizations to develop standards for a voluntary certification in the management of the patient with diabetes in the inpatient setting. It is important that food and nutrition professionals familiarize themselves with these recommendations and implement nutrition interventions in collaboration with other members of the health care team to achieve these new glycemic control targets. Food and nutrition professionals have a key role in developing screening tools, and in implementing nutrition care guidelines, nutrition interventions, and medical treatment protocols needed to improve inpatient glycemic control.

Nutrition therapy for the hospitalized patient with diabetes.

OBJECTIVE: To summarize recommendations for medical nutrition therapy (MNT), including how to implement it to achieve glycemic control targets for hospitalized patients with diabetes. METHODS: The MNT goals for hospitalized patients with diabetics are reviewed, and suggestions are made for attaining these goals. Emphasis is placed on the importance of proper screening and referral of inpatients to MNT service and on the process of providing MNT in the hospital setting. RESULTS: Implementing MNT in the hospital can be challenging because of the differences in nutrient and medication requirements compared with the home setting. Individualization of MNT during hospitalization, along with intensive medical management, generally is required if patients with diabetes are to achieve blood glucose targets. Barriers that may impact an individual's nutrition status and subsequently affect glycemic control include poor appetite, inability to eat, increased nutrient and calorie needs due to catabolic stress, variation in diabetes medications, and the possible need for enteral or parenteral nutrition support. There is limited evidence on what constitutes the optimal diet for hospitalized patients with diabetes. The consistent carbohydrate meal-planning system has been recommended because carbohydrate intake is the primary nutritional influence on blood glucose; this system focuses on the total grams of carbohydrate as the key strategy to achieve blood glucose control. Introduction of the consistent carbohydrate system requires that all healthcare disciplines understand the rationale of the system; and for the system to be effective, coordination must exist between nursing and nutrition services. Established guidelines for integration of diabetes medications with meals, snacks, or nutrition support, developed by a multidisciplinary healthcare team, will help ensure that the nutrition care plan works together with the medical treatment plan. The key areas of focus to improve inpatient glycemic control are: establishing screening criteria for appropriate referral to a registered dietitian; identifying nutrition-related issues in clinical pathways and patient care plans; implementing and maintaining standardized diet orders such as consistent carbohydrate menus; integrating blood glucose monitoring results with nutrition care plans; using standing orders for diabetes education and diabetes MNT as appropriate; and standardizing discharge follow-up orders for MNT and diabetes education post-discharge when necessary.