Myths & facts about diabetic hypoglycemia

Impact of improvement efforts on glycemic control and hypoglycemia at a university medical center

BACKGROUND

Great emphasis is placed on optimizing treatment of hospitalized patients with diabetes and hyperglycemia.

OBJECTIVE

This study was conducted to determine if the application of hospital-wide insulin order sets improved inpatient safety by reducing the number of actual hypoglycemic and hyperglycemic events and increasing at-target blood glucose.

DESIGN

A retrospective chart review was conducted of hypoglycemic and hyperglycemic events and at-target blood glucose occurring before and after institution of the insulin order sets and blood glucose protocols.

SETTING

The Medical University of South Carolina (MUSC) Medical Center is a 709-bed hospital and tertiary referral center for partnering hospitals in the southeastern United States.

PATIENTS

All patients were evaluated who had a documented history of diabetes or who had at least 1 finger-stick blood glucose above 180 mg/dL who were admitted for care to the MUSC adult main hospital (minimum of 18 years-of-age; maximum 100 years-of-age) during June 2004, June 2005, June 2006, and June 2007.

INTERVENTION

The intervention involved institution of hospital-wide hypoglycemia, hyperglycemia, subcutaneous insulin, and intravenous insulin treatment protocols.

MEASUREMENTS

Retrospective data on hypoglycemia, hyperglycemia, and at-target blood glucose incidence and frequency were collected via a computerized repository for all inpatients.

RESULTS

The percent time in range improved by 10% with no increase in the amount of severe hypoglycemic episodes for the blood glucose results.

CONCLUSIONS

Implementing standardized insulin order sets including hypoglycemia and hyperglycemia treatment protocols at MUSC produced expected benefits for patient safety for this patient population.

Hospital hypoglycemia: not only treatment but also prevention

OBJECTIVE

To propose a strategy, applicable on general hospital wards, for prevention of hypoglycemia in hospitalized patients.

RESULTS

Although the mortality rate among hospitalized patients with hypoglycemia has been shown to be 22.2 to 27% in series that included patients with diabetes, some investigators have shown that hypoglycemia is not an independent predictor of mortality. Outside the critical care setting, the comparative risks of hyperglycemia and hypoglycemia and the relationship of hospital hypoglycemia to intensification of glycemic control have not been determined. The reported incidence of hospital hypoglycemia ranges from 1.2% for hospitalized adults to 20% for nonpregnant patients with diabetes admitted without a metabolic emergency. Among patients receiving antihyperglycemic therapy, the literature describes precipitating events--usually a sudden change of caloric exposure-- and predisposing conditions for hypoglycemic episodes.

CONCLUSION

Hospital hypoglycemia is predictable, and it is preventable by measures other than undertreatment of hyperglycemia. Physician orders for antihyperglycemic therapy should be written and, if necessary, be revised so as to respond to the presence of predisposing conditions for hypoglycemia. A ward-based protocol or hospital-wide policy should establish the appropriate response to triggering events. Within the time frame of action of previously administered antihyperglycemic drugs (after abrupt interruption of caloric exposure), the threshold for preventive intravenous administration of dextrose is a glucose concentration of 120 mg/dL.