Unlike the other common diabetes emergency, diabetic ketoacidosis (DKA), guidelines on the management of the hyperglycaemic hyperosmolar state (HHS) in adults are uncommon and often there is little to differentiate them from the management of DKA. However, HHS is different and treatment requires a different approach.
The person with HHS is often elderly, frequently with multiple co-morbidities but always very sick. Even when specific hospital guidelines are available, adherence to and use of these is variable amongst the admitting teams. In many hospitals these patients are managed by non-specialist teams, and it is not uncommon for the most junior member, who is least likely to be aware of the hospital guidance, to be given responsibility for the initial management of this complex and challenging condition. Diabetes specialist teams are rarely involved at an early stage and sometimes never at all.