Primary prevention
Effective prevention of both inpatient hyperglycaemia and hypoglycaemia requires a comprehensive, multifaceted approach combining clinical expertise, technological support, and standardised system-wide protocols. Early identification of patients at risk, frequent and accurate blood glucose monitoring, and proactive adjustments to glucose-lowering therapies are essential components to maintain safe glycaemic levels.[1] Establishing hospital-wide protocols ensures consistency and safety in treatment practices.[1] Episodes of hypoglycaemia in the hospital should be documented in the health record and tracked to inform quality improvements.[1]
Human intervention plays a central role, with multidisciplinary teams - including nurses, physicians, dietitians, and diabetes consultants - responsible for developing and implementing strategies to improve glycaemic monitoring, coordinating nutrition and insulin administration, and providing patient and staff education.[27] Nurse-led protocols, insulin-meal matching, and dedicated hypoglycaemia committees have been shown to significantly reduce adverse glycaemic events.[27] The American Diabetes Association (ADA) recommends that every hospital or healthcare system adopt a hypoglycaemia prevention and management protocol, including a standardised, nurse-initiated treatment protocol to promptly address blood glucose levels <3.9 mmol/L (<70 mg/dL), with any value below this threshold triggering a review of the patient’s treatment plan due to increased risk of severe hypoglycaemia.[1] A plan for identifying, treating, and preventing hypoglycaemia should be established for every patient with diabetes who is hospitalised.[1]
Technology also plays a crucial role in primary prevention. Electronic prescribing systems can enhance insulin safety by reducing errors and supporting appropriate insulin self-administration in hospitals.[28] Computerised clinical decision support systems and predictive algorithms enhance prevention efforts by identifying patients at high risk of dysglycaemia, enabling timely intervention and safer insulin dosing.[27] Integration of these tools into electronic health records facilitates consistent application across hospitals and supports evidence-based care, although current models have limitations in prediction accuracy and individual patient variability.[27]
The ADA and Joint British Diabetes Societies (JBDS) support the continued use of continuous glucose monitoring (CGM) and insulin pumps during hospitalisation when patients can safely manage them under appropriate clinical supervision.[1][28][29] Hospitals are encouraged to establish policies to support inpatient use of diabetes technology and integrate device data into electronic health records to optimise glycaemic management.[1]
Secondary prevention
Secondary prevention in inpatient glycaemic management aims to promptly identify and mitigate episodes of hyperglycaemia and hypoglycaemia once they occur, minimising complications and preventing recurrence during the hospital stay.
Key strategies include:
Frequent monitoring and early detection: Continuous or frequent blood glucose monitoring, using capillary blood glucose testing or continuous glucose monitoring (CGM), is essential for timely recognition of glycaemic excursions. Real-time data allow for immediate adjustments to therapy.[1]
Timely treatment adjustments: Rapid modification of insulin or other glucose-lowering therapies based on current glucose trends helps restore and maintain euglycaemia. This includes correcting hyperglycaemia with appropriate insulin dosing and promptly treating hypoglycaemia with carbohydrate administration or glucagon as indicated.[4]
Protocol-driven management: Implementation of standardised hospital protocols for treating hyper- and hypoglycaemia ensures consistent, evidence-based responses across care teams.[1] Nurse-initiated hypoglycaemia treatment protocols can reduce treatment delays.[27]
Multidisciplinary coordination: Coordination among physicians, nurses, dietitians, and diabetes consultants enhances patient-specific management and education, reducing the risk of recurrent episodes.[27]
Patient and staff education: Educating patients and clinical staff on recognising symptoms, risk factors, and appropriate interventions supports secondary prevention efforts.[27]
Use of technology: Integration of clinical decision support systems and CGM alerts can aid in early identification of trends towards hypo- or hyperglycaemia, allowing pre-emptive adjustments.[1][4][27]
Documentation and quality improvement: Episodes of hypoglycaemia in the hospital should be documented in the health record and tracked to inform quality improvements.[1] Diabetes teams should review any serious untoward incidents where hypoglycaemia has been a factor and develop strategies for future prevention.[73]
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