Reducing severe hypoglycaemia in hospitalised patients with diabetes: Early outcomes of standardised reporting and management

Inpatient Hypoglycemic Rate Reduction Through the Implementation of Prescriber Targeted Decision Support Tools

PURPOSE OF REVIEW

Hypoglycemia has been shown to increase mortality and length of hospital stay and is now reportable to the Centers for Medicare and Medicaid Services as a quality measure. The purpose of this article is to review clinical decision support (CDS) tools designed to reduce inpatient hypoglycemic events.

RECENT FINDINGS

CDS tools such as order set development, medication alerts, and data visibility have all been shown to be valuable tools in improving glycemic performance. This is especially true for hyperglycemic events with mixed results in hypoglycemia prevention. CDS solutions may be targeted directly to healthcare professionals or to specialty diabetes management teams to reduce hypoglycemia. Not all organizations have the financial resources to develop a diabetes management team so non-interruptive alerts may serve as an important tool to alert health care professionals of individuals with additional risk factors for the development of hypoglycemia. CDS can provide a mechanism to reduce the risk of hypoglycemia in hospitalized individuals. Although new research is promising, more studies are needed to determine future directions including the impact and feasibility of continuous glucose monitoring and predictive models to improve overall glycemic performance.

Factors influencing knowledge translation into critical care practice: The reality facing intensive care nurses in Limpopo Province

Background

Nurses working in intensive care units (ICUs) must incorporate new knowledge and evidence-based practice (EBP) into their daily routines to enhance patient outcomes. However, this integration often falls short in ICU settings. Weekly clinical audits reveal incidents where ICU nurses neglect evidence-based interventions, impacting patient outcomes and ICU stays.

Objectives

To explore the factors influencing the translation of knowledge into ICU practice.

Methods

We conducted exploratory, qualitative research to investigate ICU nurses' perspectives on knowledge translation into ICU practices. The study employed purposive sampling to select ICU nurses. We used paired interviews and group discussions to gather insights from ICU nurses regarding the factors influencing the translation of knowledge into ICU practices. Data analysis was performed using Boomer and McCormack's nine steps of creative hermeneutic data analysis.

Results

One main theme, 'We are just surviving' emerged, encompassing two sub-themes: management and workplace culture. Under management, participants described barriers, such as resource scarcity, behaviour, outdated evidence-informed protocols and workload. Under workplace culture, participants mentioned negative attitudes and a lack of teamwork, contributing to poor-quality care.

Conclusion

In ICUs, nurses are expected to integrate new knowledge and scientific evidence into their daily practice, yet they face challenges in doing so. Interventions should be implemented to address management and workplace culture.

Contribution of the study

This study raised awareness for the intensive care nurse practicioner to intergrate new knowledge and scientific evidence into clinical practice. This study highlighted the importance of teamwork and collaboration between nurses and doctors to ensure knowledge translation and quality care of the critical ill/injured patients. This study confirmed that support from management is vital to address challenges such as workload, staff shortage, inadequate equipment and outdated protocols as these aspects impact negatively on intensive care nurses ability to transfer knowledge into clinical practice.

Pharmacy stewardship to reduce recurrent hypoglycemia

BACKGROUND

Inpatient hypoglycemia is associated with increased morbidity and mortality. After a hypoglycemic event, the likelihood of additional episodes increases. The Joint Commission recommends evaluating all episodes of hypoglycemia for root-cause analysis. Studies have shown that pharmacists' involvement with glycemic control protocols can prevent hypoglycemia.

OBJECTIVES

This study aimed to assess whether the implementation of pharmacists' real-time assessment of hypoglycemic events using an electronic alert messaging system contributes to the reduction of the number of recurrent hypoglycemia during hospitalization.

PRACTICE DESCRIPTION

A community hospital that provides a wide range of health care services. The pharmacy department provides fully decentralized clinical services and team-based specialist services.

PRACTICE INNOVATION

The pharmacist-led hypoglycemia stewardship initiative included a comprehensive review of hypoglycemic alerts received via an automated message. The alerts generated in the electronic health record (EHR) every time a patient's blood glucose resulted in less than 70 mg/dL if there was a documented administration of a hypoglycemic agent 48 hours before the hypoglycemia event. Once the alert was received by the pharmacists via an EHR in-basket, a real-time review was conducted to identify the potential causes of the event and opportunities for therapy modification.

EVALUATION METHODS

A single-center retrospective observational study including a pre- and post-implementation phase from January 1 to June 3, 2020, and January 1 to June 30, 2021, respectively. Continuous data were analyzed using paired and equal variance t test. Noncontinuous data were analyzed using Fisher exact and chi-square test. Descriptive statistics were used to describe distribution and frequency of data.

RESULTS

There was a 5.1% absolute reduction in recurrent hypoglycemic events (P < 0.001) and a 0.6% reduction of severe hypoglycemic days (P = 0.269) in the postimplementation group. The average time to pharmacist intervention was 4 (± 3.5) hours with a 92% acceptance rate.

CONCLUSION

This study demonstrated the utility of pharmacist-led hypoglycemia reviews in the reduction of recurrent hypoglycemic events in the inpatient setting.

Hypoglycemia: Comparison of Health Status Outcomes Between Patients After Allogeneic Hematopoietic Cell Transplantation

BACKGROUND

Patients who have undergone hematopoietic cell transplantation (HCT) often face lengthy hospital stays. Hospitalized patients' compromised health status puts them at risk for complications to recovery when glucose is not controlled.

OBJECTIVES

This study aimed to investigate differences in outcomes in patients who experienced hypoglycemia compared to patients who did not experience hypoglycemia post-allogeneic HCT.

METHODS

A retrospective chart review and secondary data analysis were conducted. The sample consisted of 198 adult patients hospitalized for their first allogeneic HCT at the University of Minnesota Medical Center between August 2015 and December 2017. Hypoglycemic patients were compared with nonhypoglycemic patients until discharge or 100 hospitalization days post-transplantation.

FINDINGS

A total of 20 patients (10%) experienced hypoglycemic events during the study time frame. There were significant differences between the two groups. Hypoglycemia may be a marker for higher acuity illness in this population. Nurses should increase vigilance in managing the blood glucose levels of patients undergoing HCT with known comorbidities and complications.

Adherence to a Hypoglycemia Protocol in Hospitalized Patients: A Retrospective Analysis

BACKGROUND

Hypoglycemia can be a common occurrence in hospitalized patients, both those with and without diabetes. Hypoglycemia poses significant risks to hospitalized patients, including increased mortality.

OBJECTIVES

This was a retrospective pre-post study of hypoglycemic patients in an academic medical center of an intervention to improve timely staff nurse adherence to a hypoglycemia protocol. The number of mild and severe hypoglycemia events pre- and postintervention, timeliness of adherence to the hypoglycemia protocol, the number of treatment interventions, and time to return patients to euglycemia were analyzed.

METHODS

Data from hospitalizations of patients who experienced hypoglycemia (<70 mg/dl) and met inclusion criteria 1 year prior to intervention and 3 years postintervention were extracted, including demographics, glycemic control medications, diagnostic-related group, length of stay, and Charlson comorbidity index. For clarity and to determine if any significant change was sustained, the analysis compared data from 1 year prior to intervention to the second-year postintervention.

RESULTS

A total of 7,895 unique hypoglycemic events in 3,819 patients experiencing 20,094 hypoglycemic measures were included in the analysis. Patients were primarily adult, female, and White. Only 58.7% of the sample had diabetes; the median Charlson comorbidity index was 6. Results demonstrated improvement postintervention to registered nurse hypoglycemia protocol adherence regardless of age category or hypoglycemia severity. There was a significant reduction in median time from the first hypoglycemia measure to the second measure. In addition, there was a significant difference in the number of treatment interventions and reduction in time from the first hypoglycemia measure to return of patient to a blood glucose of ≥70 mg/dl.

DISCUSSION

These study results support that the use of a standardized hypoglycemia protocol and appropriate nurse workflows enables nurses to manage hypoglycemia promptly and effectively in most acute and critically ill hospitalized patients. Results also supported a differentiation in nurse workflow for patients with mild versus severe hypoglycemia. Implementing these interventions may result in avoidance or mitigation of the potential consequences of severe and/or sustained hypoglycemia.

Multidisciplinary strategies to treat severe hypoglycemia in hospitalized patients with diabetes mellitus reduce inpatient mortality rate: Experience from an academic community hospital

Objective

Severe hypoglycemia (blood glucose < 50 mg/dl) in hospitalized patients with diabetes mellitus is associated with poor outcomes such as increased mortality and readmission rates. We study the effects of system based interventions in managing severe hypoglycemia and its impact on outcomes.

Research design and methods

We performed retrospective review of pre- and post- intervention study to quantify severe hypoglycemia in patients admitted in the general internal medicine wards with primary or secondary diagnosis of diabetes mellitus based on ICD-9 and ICD-10 codes. We implemented multidisciplinary interventions including standardization of treatment, education of in-patient medical teams and physician notification and feedback immediately after severe hypoglycemia. The endpoints were the comparative analysis of incidence of severe hypoglycemia, in-patient mortality rate, 30-day mortality rate, 30-day readmission rate, recovery time from hypoglycemia, time to next glucose measurements, use of standardized treatment and physician notification rate pre-and post-intervention.

Results

The incidence of severe hypoglycemia per patient with diabetes was reduced from 9.6% (233/2416) to 5.6% (202/3607) (p<0.001) post-intervention. The in-patient mortality rate in patients with severe hypoglycemia reduced from 4.1% to 0% (p = 0.019), 30-day mortality rate reduced from 9.8% to 3.8% (p = 0.058) post-intervention. 30-day readmission rate was comparable between pre-intervention (31.7%) and post-intervention (29%) (p = 0.60). In comparison, the mortality and readmission rates of all diabetic patients did not reduce during the same observation periods. Recovery time reduced from 116 (83–161) to 75 (57–102) min (p<0.01), time to next glucose measurement reduced from 39.5 (34–48) to 32 (28–35) min (p<0.01), use of standardized treatment improved from 22.7% (53/233) to 72.2% (146/202) (p<0.001) and physician notification rate increased from 29.2 (68/233) to 84.7% (171/202) post-intervention.

Conclusions

Our study shows that multidisciplinary strategies improves the process of early detection and management of severe hypoglycemia and reduce incidence and in-patient mortality rate.

Postoperative Management in Patients with Pheochromocytoma and Paraganglioma

Pheochromocytomas and paragangliomas (PPGLs) are rare catecholamine-secreting neuroendocrine tumors of the adrenal medulla and sympathetic/parasympathetic ganglion cells, respectively. Excessive release of catecholamines leads to episodic symptoms and signs of PPGL, which include hypertension, headache, palpitations, and diaphoresis. Intraoperatively, large amounts of catecholamines are released into the bloodstream through handling and manipulation of the tumor(s). In contrast, there could also be an abrupt decline in catecholamine levels after tumor resection. Because of such binary manifestations of PPGL, patients may develop perplexing and substantially devastating cardiovascular complications during the perioperative period. These complications include hypertension, hypotension, arrhythmias, myocardial infarction, heart failure, and cerebrovascular accident. Other complications seen in the postoperative period include fever, hypoglycemia, cortisol deficiency, urinary retention, etc. In the interest of safe patient care, such emergencies require precise diagnosis and treatment. Surgeons, anesthesiologists, and intensivists must be aware of the clinical manifestations and complications associated with a sudden increase or decrease in catecholamine levels and should work closely together to be able to provide appropriate management to minimize morbidity and mortality associated with PPGLs.