Reading the exchange of letters in the December 2005 issue regarding the management of inpatient hyperglycemia made me reflect on personal experiences as a hospital patient (1,2). In past years, as surgeons and cardiologists tended to their more immediate tasks, my diabetes was often relegated to a secondary and sometimes seemingly nonexistent concern. I was frustrated and angered by substitution of the sliding-scale for my normal insulin regimen, especially as my blood glucose spiraled out of control. It is encouraging that this critical issue is receiving increased attention.
My own bouts with surgeries at the University of Pittsburgh Medical Center this past winter highlight the benefits of focusing on inpatient diabetes management. Not only did I demand a consult with my endocrinologist and her staff to develop and implement a treatment plan for my hospital stay, I requested intravenous insulin infusions during surgery and in the recovery room and intensive care unit. The growing evidence supporting the value of infusions is overwhelming.
It is sometimes easy, however, to overlook another effective tool for in-hospital diabetes management— the patient. Undoubtedly, the most helpful step for me was continuing to manage my own insulin pump therapy while in the hospital. Clearly, every patient demonstrating proficiency, whether using a pump or multiple insulin injections, should be encouraged to continue self-management on the nursing floor. For me, this alleviated the anxieties often felt by patients when their diabetes management routines have been disrupted. And the results were phenomenal. My blood glucose stayed within normal ranges almost the entire time! With the help and oversight of my consulting endocrinologist and certified diabetes educators, self-management presented few difficulties for me and relieved the surgical staff of this additional responsibility. Many of the nurses and other hospital staff were actually curious to learn more about insulin therapy and, particularly, pump therapy.
I kept my own glucose monitor and a supply of strips with me, as well as replacement batteries and other pump supplies. While staff would routinely check my blood glucose levels, the timing was somewhat irregular and did not always correlate with meals. I carefully recorded monitor readings, food intake, and insulin dosing to review with my consulting diabetes specialists. I also maintained a cache of glucose tablets and fruit juice to treat inevitable lows. Although these were available on the hospital floor, I was concerned about getting the immediate attention of the nursing staff during a sudden hypoglycemic episode. Nevertheless, I reported every incident and the actions taken for entry into my medical records.
In addition, I reminded every hospital staff member about my diabetes and my treatment plan, and I always had a family member available to do this when I was unable to speak for myself. While this information was contained in my chart, it is unreasonable to expect that everyone remembers every detail all the time. These approaches kept my diabetes in the forefront and dramatically enhanced each hospitalization.
This letter may seem “far out,” but in my experience and that of some of my colleagues, with select patients, usually type 1’s, patient self-management (with physician oversight) yields better glycemic results (and less patient and physician anxiety) than if insulin dosing is left to the vagaries of the busy floor staff. Getting the hospital administration to allow this is often the biggest challenge.