Managing inpatient hyperglycemia in a resource-constrained county hospital: the Parkland Memorial Hospital experience.

Diabetes is a common comorbidity among hospitalized patients and has been linked to increased length of stay, morbidity, and mortality. In addition, multiple pathophysiological factors contribute to incident hyperglycemia in a sizable proportion of inpatients without previously diagnosed diabetes. Insulin is the mainstay of therapy for inpatient management of diabetes and hyperglycemia. In this article, we discuss initial treatment planning and insulin initiation for established and treatment-naïve patients with diabetes who are being treated with human and analog-based insulin therapy. As a publicly funded and cost-conscious hospital, we rely on human insulin for first-line therapy and generally find good results, reserving more costly insulin analogs for patients with type 1 diabetes. We also describe a novel continuous insulin-infusion protocol, the Parkland glucose insulin infusion protocol, which controls severe hyperglycemia safely and effectively in hospitalized patients who are unable to tolerate oral nutrition or are in other complicated clinical situations. We outline transitions from intravenous to subcutaneous insulin and other planning and diabetes education necessary to facilitate discharge. Lastly, we discuss steps for the development and implementation of a continuous intravenous insulin-infusion protocol at the institutional level.