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BMJ Quality Improvement Report
Reducing severe hypoglycaemia in hospitalised patients with diabetes: Early outcomes of standardised reporting and management
  1. Katherine A Araque1,
  2. Deepak K Kadayakkara1,
  3. Nino Gigauri1,
  4. Diane Sheehan2,
  5. Sachin Majumdar3,
  6. Gregory Buller1,
  7. Clare A Flannery4
  1. 1 Internal Medicine Department, Yale New Haven Health Bridgeport Hospital, Bridgeport, Connecticut, USA
  2. 2 Endocrinology Department, Yale New Haven Health Bridgeport Hospital, Bridgeport, Connecticut, USA
  3. 3 Endocrinology Department, Yale New Haven Health Bridgeport Hospital, Bridgeport, Connecticut, USA
  4. 4 Section of Endocrinology, Internal Medicine Department,, Yale School of Medicine, New Haven, Connecticut, USA
  1. Correspondence to Dr Gregory Buller; Gregory.buller{at}bpthosp.org

Abstract

Background Severe hypoglycaemic events (HGEs) in hospitalised patients are associated with poor outcomes and prolonged hospitalization. Systematic, coordinated care is required for acute management and prevention of HGEs; however, studies evaluating quality control efforts are scarce.

Objective To investigate the effectiveness of system-based interventions to improve management response to HGEs.

Methods System-based interventions were designed and implemented following a root cause analysis of HGE in adult patients with diabetes from two general medical wards with the highest incidence of HGE. Interventions included electronic medical record programming for a standardised order set for basal-bolus insulin regimen and hypoglycemia protocol, automated dextrose order, automated MD notification, and recommendation for endocrine consultation after two critical HGEs. The Pyxis MedStation was programmed to alert nurses to recheck blood glucose 15 min after the treatment. A card with the HGE management protocol was attached to each provider’s ID badge and educational seminars were given to all providers.

Main outcomes and measures Primary outcomes were to evaluate median time from HGE (glucose <50 mg/dL) to euglycemia (>100 mg/dL), and time from HGE to follow-up finger-stick (FS) testing preintervention and postintervention. Secondary outcomes were cumulative incidence of HGEs, recurrent hypoglycemia, rate of physician notification and use of standardised treatments among adults with diabetes on the two general medical wards.

Results Among hospitalised adults with diabetes and HGE, median time from HGE to euglycemia declined from 225±46 min preintervention to 87±26 min postintervention (p=0.03). Median time from HGE to next FS testing also declined (76±14 min to 28±10 min, p<0.001). Standardised treatment administration for HGE improved significantly from 34% (12/35) to 97% (36/37); physician notification rate improved significantly from 51% (18/35) to 78% (29/37).

Among hospitalised adults with diabetes, incidence of HGE decreased from 12% (35/295) over 3 months (preintervention period) to 6% (37/610) over 6 months (postintervention period) (p<0.001), while recurrent HGE did not show significant differences (37% (13/35) to 24% (9/37) , p=0.09).

Conclusions System-based interventions had a clinically important impact on decreasing time from HGE to euglycemia and to next FS testing. This hypoglycemia bundle of care may be applied and tested in other community hospitals to improve patient safety.

  • quality improvement
  • decision support
  • clinical
  • diabetes mellitus
  • patient safety
  • hospital medicine

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/bmjoq-2017-000120

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    Footnotes

    • Contributors KAA, DKK, GB and CAF had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: KAA, GB, CAF. Acquisition, analysis or interpretation of data: KAA, DKK, NG, GB, CAF. Drafting of the manuscript: KAA, GB, CAF. Critical revision of the manuscript for important intellectual content: All authors.Statistical analysis: KAA, DKK, CAF, GB. Obtained funding: Bridgeport Hospital Internal Medicine Department. Administrative, technical or material support: Bridgeport Hospital. Study supervision: CAF.

    • Funding Yale New Haven Health Bridgeport Hospital had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data. All authors re viewed the manuscript prior to submission. The funding organisations otherwise had no role in the preparation and decision to submit the manuscript for publication.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.