Executive Summary Checklist
Severe hypoglycemia (SH) causes significant morbidity and occasional mortality in hospitalized patients. The establishment of an effective program to reduce errors in the recognition and treatment of SH requires an implementation plan that includes the following actionable steps:
- Establish a commitment from hospital administration and medical leadership to reduce SH.
- Raise institutional awareness of the issue by comparing hospital and nursing units based on performance quality scorecards.
- Create a multidisciplinary team that includes physicians, pharmacists, nurses, diabetic educators, medication safety officers, case managers, and long-term healthcare professionals. This team will:
- Develop a system to identify patients receiving anti-diabetic medications (sulfonylureas, insulins, etc.) in the Electronic Health Record (EHR).
- Implement real-time surveillance methods, analysis tools, and point-of-care blood glucose (BG) monitoring and reporting systems.
- Create insulin order sets that could be modified to reduce risks of hypoglycemia.
- Coordinate glucose monitoring, automate insulin dose calculations, insulin administration, and meal delivery during changes of shift and times of patient transfer.
- Develop a systematic approach to reduce SH and implement universal best practices.
- Continuously monitor the incidence of SH in the hospital, and use the results of this monitoring in medical staff education sessions as a part of Continuous Quality Improvement (CQI).
The Performance Gap
Hypoglycemia is a common problem for many patients with diabetes, and it can also occur in non-diabetics in a hospital setting. . Mild episodes can cause unpleasant symptoms and disrupt daily activities. Severe hypoglycemia (SH) can result in disorientation and unusual behavior, and may be life-threatening. Frequent hypoglycemia is associated with increased morbidity, length of stay, and mortality. Hypoglycemia has been associated with mortality in the intensive care units \cite{Elliott_2012}. Moderate and SH are strongly associated with increased risk of death, especially from distributive shock \cite{2012}. This is by means of impairment of autonomic function, alteration of blood flow and composition, white cell activation, vasoconstriction, and the release of inflammatory mediators and cytokines \cite{Adler_2008},\cite{Wright_2008}. The prevalence of hypoglycemia (serum glucose <70 mg/dL) was reported as 5.7% of all point-of-care blood glucose (BG) tests in a 2009 survey of 575 hospitals.\cite{Swanson_2011}. The definition of SH (a low BG level that requires the assistance of another person for recovery), is a level <40 mg/dL, has been adopted as the level likely to cause harmin the hospital setting \cite{Schwartz_2007}. SH is a preventable harm. Early therapeutic management of mild hypoglycemia can prevent more SH episodes. In addition, literature showed that clinicians do not consistently adjust their patient’s anti-diabetic regimens appropriately following treatment of hypoglycemia, placing the patient at additional risk \cite{Boucai_2011},\cite{DiNardo_2006}.
Causative factors that may lead to the development of hypoglycemia for inpatients may include excessive insulin dose, inappropriate timing of insulin or anti-diabetes therapy, unaddressed antecedent hypoglycemia or changes in the nutritional regimen, creatinine clearance changes, or steroid dose (9)\cite{Deal_2011}. Failure of effective BG monitoring and communication between physicians, pharmacists and nurses can also contribute to the problem. The diverse nature of potential errors in the treatment of inpatients with SH supports the need for a decision-making model that can be used to predict and prevent SH episodes and improve overall patient safety and outcomes.
Closing the performance gap will require hospitals and healthcare systems to commit to action in the form of specific leadership, practice, and technology plans.
Leadership Plan
- The plan must include the fundamentals of change outlined in the National Quality Forum safe practices, including awareness, accountability, ability, and action \cite{51}.
- Hospital governance and senior administrative leadership (medical, pharmacy, and nursing) must fully understand the performance gaps in their own healthcare system.
- Hospital governance, senior administrative leadership, and clinical/safety leadership must close their own performance gaps by implementing a comprehensive approach.
- Hospitals should set a goal date for the implementation of the corrective plan, with measurable quality indicators and milestones.
- Specific budget allocations for the plan should be evaluated by governance boards and senior administrative leaders.
- Clinical/safety leadership should endorse the plan and ensure implementation across all providers and systems.
Practice Plan
- Each hospital should create a multidisciplinary team, which includes physicians, pharmacists, nurses, diabetic educators, medication safety officers, case managers, and long-term healthcare professionals).
- Develop a systematic approach to reducing severe hypoglycemia:
- Identify events and prioritize
- Raise institutional awareness
- Compare hospitals and nursing units based on performance quality scorecards (use harm rate for at-risk patient days: # of events/# of patient days during hospital stay when a diabetic agent is ordered at any time)
- Encourage nurses to enter hypoglycemia into safety event self-reporting site
- Communicate to the hospital leadership board
- Send letters to physicians and providers (from case managers)
- Educate hospital staff, providers and patients – hospital newsletter and posters made for each hospital/nursing unit listing known and assumed solutions to hypoglycemia (e.g., “STOP Hypoglycemia!”)
- Kickoff reception for safety initiative
- Frequent monitoring of glucose levels in patients who are at risk.
- Implement foundational Best Practices and “Just Do Its” (Appendices A and B)
- Establish a Hypoglycemia Task Force for the hospital ○Propose multidisciplinary diabetes safety team at each hospital
- Adopt foundational best practices (literature-based recommendations for all hospitals)
- Implement “Just Do Its!” (or “Start Nows”) – these should be safe and reasonable interventions tested internally
- Adopt ISMP recommendations for U-500 insulin precautions (Appendix C)
- Event investigation and collect causative factors
- Causative Factors (to consider as part of analysis tool):
- Insulin stacking
- Wrong drug, dose, route, patient, or time
- Insufficient glucose monitoring
- Basal heavy regimen
- Decreased nutritional intake
- Event related to outpatient or emergency department drug administration
- Event while treating elevated potassium
- Glucose trend not recognized
- High dose sliding scale insulin 10
- Home regimen continued as inpatient
- Significant reduction in steroid dose
- Sulfonylurea-related hypoglycemia
- Insulin administration and food intake not synchronized
- POC glucose reading not linked to insulin administration
- POC glucose reading not synchronized with food intake
- Analysis tool forms reviewed by either pharmacist and/or nurse in a timely manner (e.g., 72 hours) for causative factors; communicate findings with physician(s)
- Results are collated and reported to Medication Safety Committee and the Pharmacy and Therapeutics Committee
- Identify interventions (evidence-based and expert opinion) that are used to resolve the most common or most harmful causative factors
- Track the interventions and create customized action plans based on an integrated results dashboard
- Share best practices within hospital and to other hospitals
- Share strategies and implement informed interventions on target floors and patients.
Technology Plan
Suggested practices and technologies are limited to those proven to show benefit or are the only known technologies with a particular capability. As other options may exist, please send information on any additional technologies, along with appropriate evidence, to info@patientsafetymovement.org. - Implement glycemic management clinical decision support for insulin therapy recommendation, based on individual responses to insulin and designed for mitigation of all types of hypoglycemia.
- This would include all of the following bullet points with significant additional safety features.
- Implement real-time surveillance method for informatics alerts: “High-Risk Sulfonylurea Alert” and “Hypoglycemia Risk Alert”.
- Implement an automated hypoglycemia event analysis tool (to discover local causes of hypoglycemia and guide future interventions).
- Implement point-of-care BG monitoring and reporting systems, including quality assurance reports to audit compliance with hypoglycemia management goals and restriction of insulin utilization.
- Implement automated triggers for most common causative factors of hypoglycemia, an electronic tracking system for SH events, interventions used and clinical outcomes.
- Implement a results dashboard for each nursing unit within the hospital and Best Practices used to resolve the hypoglycemic event(s).
- Set restrictions for the prescribing of U-500 Regular Insulin to only specialists and under special circumstances in CPOE.