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Current Diabetes Reports

, 17:74 | Cite as

How Low Can You Go? Reducing Rates of Hypoglycemia in the Non-critical Care Hospital Setting

  • Kristen Kulasa
  • Patricia Juang
Hospital Management of Diabetes (A Wallia and JJ Seley, Section Editors)
  • 360 Downloads
Part of the following topical collections:
  1. Topical Collection on Hospital Management of Diabetes

Abstract

Purpose of Review

The purpose of this review is to discuss strategies to reduce rates of hypoglycemia in the non-critical care setting.

Recent Findings

Strategies to reduce hypoglycemia rates should focus on the most common causes of iatrogenic hypoglycemia. Creating a standardized insulin order set with built-in clinical decision support can help reduce rates of hypoglycemia. Coordination of blood glucose monitoring, meal tray delivery, and insulin administration is an important and challenging task. Protocols and processes should be in place to deal with interruptions in nutrition to minimize risk of hypoglycemia. A glucose management page that has all the pertinent information summarized in one page allows for active surveillance and quick identification of patients who may be at risk of hypoglycemia. Finally, education of prescribers, nurses, food and nutrition services, and patients is important so that every member of the healthcare team can work together to prevent hypoglycemia.

Summary

By implementing strategies to reduce hypoglycemia, we hope to lower rates of adverse events and improve quality of care while also reducing hospital costs. Future research should focus on the impact of an overall reduction in hypoglycemia to determine whether the expected benefits are achieved.

Keywords

Hypoglycemia Diabetes Insulin Inpatient Hospital Non-critical care 

Notes

Compliance with Ethical Standards

Conflict of Interest

Kristen Kulasa reports previously being a paid mentor for the Society of Hospital Medicine. Patricia Juang declares that she has no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Turchin A, Matheny ME, Shubina M, Scanlon JV, Greenwood B, Pendergrass ML. Hypoglycemia and clinical outcomes in patients with diabetes hospitalized in the general ward. Diabetes Care. 2009;32(7):1153–7.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Garg R, Hurwitz S, Turchin A, Trivedi A. Hypoglycemia, with or without insulin therapy, is associated with increased mortality among hospitalized patients. Diabetes Care. 2013;36(5):1107–10.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Brodovicz KG, Mehta V, Zhang Q, Zhao C, Davies MJ, Chen J, et al. Association between hypoglycemia and inpatient mortality and length of hospital stay in hospitalized, insulin-treated patients. Curr Med Res Opin. 2013;29(2):101–7.CrossRefPubMedGoogle Scholar
  4. 4.
    Nirantharakumar K, Marshall T, Hodson J, Narendran P, Deeks J, Coleman JJ, et al. Hypoglycemia in non-diabetic in-patients: clinical or criminal? PLoS One. 2012;7(7):e40384.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    • Milligan PE, Bocox MC, Pratt E, Hoehner CM, Krettek JE, Dunagan WC. Multifaceted approach to reducing occurrence of severe hypoglycemia in a large healthcare system. Am J Health Syst Pharm. 2015;72(19):1631–41. This article provides a great example of how one hospital system was able to significantly reduce severe hypoglycemia across 11 hospitals using many of the approaches mentioned in this paper.CrossRefPubMedGoogle Scholar
  6. 6.
    Finfer S, Chittock DR, Su SY, Blair D, Foster D, Dhingra V, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360(13):1283–97.CrossRefPubMedGoogle Scholar
  7. 7.
    Classen DC, Jaser L, Budnitz DS. Adverse drug events among hospitalized Medicare patients: epidemiology and national estimates from a new approach to surveillance. Jt Comm J Qual Patient Saf. 2010;36(1):12–21.CrossRefPubMedGoogle Scholar
  8. 8.
    Analytics) PATH, Analytics) WLTH, (AHRQ) SC. Costs for Hospital Stays in the United States Rockville, MD2011.Google Scholar
  9. 9.
    Classen DC, Resar R, Griffin F, Federico F, Frankel T, Kimmel N, et al. ‘Global trigger tool’ shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff (Millwood). 2011;30(4):581–9.CrossRefGoogle Scholar
  10. 10.
    Moghissi ES, Korytkowski MT, DiNardo M, Einhorn D, Hellman R, Hirsch IB, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Endocr Pract. 2009;15(4):353–69.CrossRefPubMedGoogle Scholar
  11. 11.
    Curkendall SM, Natoli JL, Alexander CM, Nathanson BH, Haidar T, Dubois RW. Economic and clinical impact of inpatient diabetic hypoglycemia. Endocr Pract. 2009;15(4):302–12.CrossRefPubMedGoogle Scholar
  12. 12.
    Carey M, Boucai L, Zonszein J. Impact of hypoglycemia in hospitalized patients. Curr Diab Rep. 2013;13(1):107–13.CrossRefPubMedGoogle Scholar
  13. 13.
    Brutsaert E, Carey M, Zonszein J. The clinical impact of inpatient hypoglycemia. J Diabetes Complicat. 2014;28(4):565–72.CrossRefPubMedGoogle Scholar
  14. 14.
    Varghese P, Gleason V, Sorokin R, Senholzi C, Jabbour S, Gottlieb JE. Hypoglycemia in hospitalized patients treated with antihyperglycemic agents. J Hosp Med. 2007;2(4):234–40.CrossRefPubMedGoogle Scholar
  15. 15.
    Michota F, Braithwaite SS. Avoiding complications in the hospitalized patient: the case for tight glycemic control. J Hosp Med. 2007;2(Suppl 1):1–4.CrossRefPubMedGoogle Scholar
  16. 16.
    Dendy JA, Chockalingam V, Tirumalasetty NN, Dornelles A, Blonde L, Bolton PM, et al. Identifying risk factors for severe hypoglycemia in hospitalized patients with diabetes. Endocr Pract. 2014;20(10):1051–6.CrossRefPubMedGoogle Scholar
  17. 17.
    American Diabetes Association. Glycemic targets. Sec 6. In Standards of Medical Care in Diabetes—2017. Diabetes Care. 2017;40(Suppl. 1):S48–56.CrossRefGoogle Scholar
  18. 18.
    Seaquist ER, Anderson J, Childs B, Cryer P, Dagogo-Jack S, Fish L, et al. Hypoglycemia and diabetes: a report of a workgroup of the American Diabetes Association and the Endocrine Society. Diabetes Care. 2013;36(5):1384–95.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Cook CB, Elias B, Kongable GL, Potter DJ, Shepherd KM, McMahon D. Diabetes and hyperglycemia quality improvement efforts in hospitals in the United States: current status, practice variation, and barriers to implementation. Endocr Pract. 2010;16(2):219–30.CrossRefPubMedGoogle Scholar
  20. 20.
    Goldberg PA, Bozzo JE, Thomas PG, Mesmer MM, Sakharova OV, Radford MJ, et al. “Glucometrics”—assessing the quality of inpatient glucose management. Diabetes Technol Ther. 2006;8(5):560–9.CrossRefPubMedGoogle Scholar
  21. 21.
    Schnipper JL, Magee M, Larsen K, Inzucchi SE, Maynard G. Society of Hospital Medicine Glycemic Control Task Force summary: practical recommendations for assessing the impact of glycemic control efforts. J Hosp Med. 2008;3(5 Suppl):66–75.CrossRefPubMedGoogle Scholar
  22. 22.
    Maynard GA, Childers D, Holdych J, Kendall H, Hoag T, Harrison K. Improving glycemic control safely in non-critical care patients: a collaborative systems approach in nine hospitals. Jt Comm J Qual Patient Saf. 2017;43(4):179–88.CrossRefPubMedGoogle Scholar
  23. 23.
    • The Glycemic Control Implementation Guide: Improving glycemic control, preventing hypoglycemia and optimizing care of the inpatient with hyperglycemia and diabetes: Society of Hospital Medicine; 2015 [second:[Available from: http://tools.hospitalmedicine.org/resource_rooms/imp_guides/GC/GC_Workbook.pdf. This guide contains step by step instructions on how to implement quality improvement strategies to improve inpatient glycemic control and reduce hypoglycemia.
  24. 24.
    Boyd JC, Bruns DE. Quality specifications for glucose meters: assessment by simulation modeling of errors in insulin dose. Clin Chem. 2001;47(2):209–14.PubMedGoogle Scholar
  25. 25.
    Blood glucose monitoring test systems for prescription point-of-care use: guidance for industry and food and drug administration staff [Internet]. 2016.Google Scholar
  26. 26.
    Klonoff DC, Draznin B, Drincic A, Dungan K, Gianchandani R, Inzucchi SE, et al. PRIDE statement on the need for a moratorium on the CMS plan to cite hospitals for performing point-of-care capillary blood glucose monitoring on critically ill patients. J Clin Endocrinol Metab. 2015;100(10):3607–12.CrossRefPubMedGoogle Scholar
  27. 27.
    Gomez AM, Umpierrez GE, Munoz OM, Herrera F, Rubio C, Aschner P, et al. Continuous glucose monitoring versus capillary point-of-care testing for inpatient glycemic control in type 2 diabetes patients hospitalized in the general ward and treated with a basal bolus insulin regimen. J Diabetes Sci Technol. 2015;10(2):325–9.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Aloi J, Bode BW, Ullal J, Chidester P, McFarland RS, Bedingfield AE, et al. Comparison of an electronic glycemic management system versus provider-managed subcutaneous basal bolus insulin therapy in the hospital setting. J Diabetes Sci Technol. 2016;Google Scholar
  29. 29.
    CMS/The Joint Commission. NQF-endorsed voluntary consensus standards for hospital care. Surgical care improvement project. 2014.Google Scholar
  30. 30.
    Maynard G, Schnipper JL, Messler J, Ramos P, Kulasa K, Nolan A, et al. Design and implementation of a web-based reporting and benchmarking center for inpatient glucometrics. J Diabetes Sci Technol. 2014;8(4):630–40.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Department of Health and Human Services. National Action Plan for Adverse Drug Event Prevention. 2014. [Available from: www.health.gov/hai/ pdfs/ADE-Action-Plan-508c.pdf.
  32. 32.
    Centers for Medicare and Medicaid Services CMS Special Innovation Project: Maintenance and Development of Medication Measures. 2013 [Available from: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/FMQAI-Glycemic-Control-Measures-Public-Comment.pdf.
  33. 33.
    Maynard G, Kulasa K, Ramos P, Childers D, Clay B, Sebasky M, et al. Impact of a hypoglycemia reduction bundle and a systems approach to inpatient glycemic management. Endocr Pract. 2015;21(4):355–67.CrossRefPubMedGoogle Scholar
  34. 34.
    Sinha Gregory N, Seley JJ, Gerber LM, Tang C, Brillon D. Decreased rates of hypoglycemia following implementation of a comprehensive computerized insulin order set and titration algorithm in the inpatient setting. Hosp Pract (1995). 2016;44(5):260–5.CrossRefGoogle Scholar
  35. 35.
    Fischer KF, Lees JA, Newman JH. Hypoglycemia in hospitalized patients. Causes and outcomes. N Engl J Med. 1986;315(20):1245–50.CrossRefPubMedGoogle Scholar
  36. 36.
    Matyka K, Evans M, Lomas J, Cranston I, Macdonald I, Amiel SA. Altered hierarchy of protective responses against severe hypoglycemia in normal aging in healthy men. Diabetes Care. 1997;20(2):135–41.CrossRefPubMedGoogle Scholar
  37. 37.
    Moen MF, Zhan M, Hsu VD, Walker LD, Einhorn LM, Seliger SL, et al. Frequency of hypoglycemia and its significance in chronic kidney disease. Clin J Am Soc Nephrol. 2009;4(6):1121–7.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Gianchandani RY, Neupane S, Iyengar JJ, Heung M. Pathophysiology and management of hypoglycemia in end stage renal disease patients—a review. Endocr Pract. 2016;Google Scholar
  39. 39.
    Arem R. Hypoglycemia associated with renal failure. Endocrinol Metab Clin N Am. 1989;18(1):103–21.Google Scholar
  40. 40.
    Mak RH. Impact of end-stage renal disease and dialysis on glycemic control. Semin Dial. 2000;13(1):4–8.CrossRefPubMedGoogle Scholar
  41. 41.
    Kovesdy CP, Park JC, Kalantar-Zadeh K. Glycemic control and burnt-out diabetes in ESRD. Semin Dial. 2010;23(2):148–56.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Hellman R. A systems approach to reducing errors in insulin therapy in the inpatient setting. Endocr Pract. 2004;10(Suppl 2):100–8.CrossRefPubMedGoogle Scholar
  43. 43.
    Elliott MB, Schafers SJ, McGill JB, Tobin GS. Prediction and prevention of treatment-related inpatient hypoglycemia. J Diabetes Sci Technol. 2012;6(2):302–9.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Farrokhi F, Klindukhova O, Chandra P, Peng L, Smiley D, Newton C, et al. Risk factors for inpatient hypoglycemia during subcutaneous insulin therapy in non-critically ill patients with type 2 diabetes. J Diabetes Sci Technol. 2012;6(5):1022–9.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Maynard G, Lee J, Phillips G, Fink E, Renvall M. Improved inpatient use of basal insulin, reduced hypoglycemia, and improved glycemic control: effect of structured subcutaneous insulin orders and an insulin management algorithm. J Hosp Med. 2009;4(1):3–15.CrossRefPubMedGoogle Scholar
  46. 46.
    •• Cobaugh DJ, Maynard G, Cooper L, Kienle PC, Vigersky R, Childers D, et al. Enhancing insulin-use safety in hospitals: practical recommendations from an ASHP Foundation expert consensus panel. Am J Health Syst Pharm. 2013;70(16):1404–13. This consensus paper provides practical recommendations to help ensure safe insulin use in hospitalized patients and minimize hypoglycemia.CrossRefPubMedGoogle Scholar
  47. 47.
    Rubin DJ, Rybin D, Doros G, McDonnell ME. Weight-based, insulin dose-related hypoglycemia in hospitalized patients with diabetes. Diabetes Care. 2011;34(8):1723–8.CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Schafers S, Naunheim R, Vijayan A, Tobin G. Incidence of hypoglycemia following insulin-based acute stabilization of hyperkalemia treatment. J Hosp Med. 2012;7(3):239–42.CrossRefPubMedGoogle Scholar
  49. 49.
    Curll M, Dinardo M, Noschese M, Korytkowski MT. Menu selection, glycaemic control and satisfaction with standard and patient-controlled consistent carbohydrate meal plans in hospitalised patients with diabetes. Qual Saf Health Care. 2010;19(4):355–9.CrossRefPubMedGoogle Scholar
  50. 50.
    Boucher JL, Swift CS, Franz MJ, Kulkarni K, Schafer RG, Pritchett E, et al. Inpatient management of diabetes and hyperglycemia: implications for nutrition practice and the food and nutrition professional. J Am Diet Assoc. 2007;107(1):105–11.CrossRefPubMedGoogle Scholar
  51. 51.
    Swift C. Nutrition therapy for the hospitalized and long-term care patient with diabetes. In: Franz M, Evert, A, editor. American Diabetes Association Guide to Nutrition Therapy for Diabetes. 2nd ed. Alexandria 2012. p. 229–45.Google Scholar
  52. 52.
    Ojo O, Brooke J. Evaluation of the role of enteral nutrition in managing patients with diabetes: a systematic review. Nutrients. 2014;6(11):5142–52.CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Umpierrez GE, Hellman R, Korytkowski MT, Kosiborod M, Maynard GA, Montori VM, et al. Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2012;97(1):16–38.CrossRefPubMedGoogle Scholar
  54. 54.
    Ryan DB, Swift CS. The mealtime challenge: nutrition and glycemic control in the hospital. Diabetes Spectr. 2014;27(3):163–8.CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Engle M, Ferguson A, Fields W. A journey to improved inpatient glycemic control by redesigning meal delivery and insulin administration. Clin Nurse Spec. 2016;30(2):117–24.CrossRefPubMedGoogle Scholar
  56. 56.
    Institute for Safe Medication Practices. Acute care guidelines for timely administration of scheduled medication. 2011. Available from: http://www.ismp.org/tools/guidelines/acutecare/tasm.pdf.
  57. 57.
    Kilpatrick CR, Elliott MB, Pratt E, Schafers SJ, Blackburn MC, Heard K, et al. Prevention of inpatient hypoglycemia with a real-time informatics alert. J Hosp Med. 2014;9(10):621–6.CrossRefPubMedGoogle Scholar
  58. 58.
    Flory JH, Aleman JO, Furst J, Seley JJ. Basal insulin use in the non-critical care setting: is fasting hypoglycemia inevitable or preventable? J Diabetes Sci Technol. 2014;8(2):427–8.CrossRefPubMedPubMedCentralGoogle Scholar
  59. 59.
    Mathioudakis N, Everett E, Golden SH. Prevention and management of insulin-associated hypoglycemia in hospitalized patients. Endocr Pract. 2016;22(8):959–69.CrossRefPubMedGoogle Scholar
  60. 60.
    HK GSJ, Lipska KJ, Je B, Lin Z, Inzucchi SE. Blood glucose trends and prediction of severe hypoglycemia in hospitalized patients. San Diego: American Diabetes Association; 2011.Google Scholar
  61. 61.
    Lee SY, Askin G, McDonnell ME, Arnold LM, Alexanian SM. Hypoglycemia rates after restriction of high-dose glargine in hospitalized patients. Endocr Pract. 2016;22(12):1393–400.CrossRefPubMedGoogle Scholar
  62. 62.
    Maynard G, Stein J. Designing and implementing effective venous thromboembolism prevention protocols: lessons from collaborative efforts. J Thromb Thrombolysis. 2010;29(2):159–66.CrossRefPubMedGoogle Scholar
  63. 63.
    Maynard GA, Morris TA, Jenkins IH, Stone S, Lee J, Renvall M, et al. Optimizing prevention of hospital-acquired venous thromboembolism (VTE): prospective validation of a VTE risk assessment model. J Hosp Med. 2010;5(1):10–8.PubMedGoogle Scholar
  64. 64.
    Maynard G, Stein J. Preventing hospital-acquired venous thromboembolism: a guide for effective quality improvement Rockville 2008 Available from: http://www.ahrg.gov/qual/veguide/.
  65. 65.
    Mendez CE, Ata A, Rourke JM, Stain SC, Umpierrez G. Daily inpatient glycemic survey (dings): a process to remotely identify and assist in the management of hospitalized patients with diabetes and hyperglycemia. Endocr Pract. 2015;21(8):927–35.CrossRefPubMedGoogle Scholar
  66. 66.
    Rushakoff R, Sullivan M, MacMaster H, editors. The virtual inpatient glucose management service: improving glucose control and decreasing therapeutic inertia. San Francisco: The American Diabetes Association Scientific Sessions; 2014.Google Scholar
  67. 67.
    Chapman JL, Lucas R, Lee J, Grimes SS, Porter AM, Bussey A. Implementation of inpatient blood glucose monitoring by clinical pharmacists. Am J Health Syst Pharm. 2013;70(17):1480–1.CrossRefPubMedGoogle Scholar
  68. 68.
    Coats A, Marshall D. Inpatient hypoglycaemia: a study of nursing management. Nurs Prax N Z. 2013;29(2):15–24.PubMedGoogle Scholar
  69. 69.
    Maynard G, Huynh M, Renvall M. Iatrogenic inpatient hypoglycemia: risk factors, treatment, and prevention analysis of current practice at an academic medical center with implications for improvement efforts. Diabetes Spectr. 2008;21(4):241–7.CrossRefGoogle Scholar
  70. 70.
    Se SF, Tucker K. Hypoglycemia prevention: an innovative approach. Nursing. 2015;45(6):19–22.CrossRefPubMedGoogle Scholar
  71. 71.
    De Alwis DT, Varadarajan S, Lim K. Notifying a doctor of a first hypoglycaemic episode is associated with a lower rate of recurrence among inpatients with diabetes. Med J Aust. 2014;200(2):79.CrossRefPubMedGoogle Scholar
  72. 72.
    Ellis R. Hypoglycaemia monitoring in a medical receiving ward. BMJ Qual Improv Rep. 2015;4(1)Google Scholar
  73. 73.
    MacEwen AW, Carty DM, McConnachie A, McKay GA, Boyle JG. A “diabetes acute care day” for medical students increases their knowledge and confidence of diabetes care: a pilot study. BMC Med Educ. 2016;16:88.CrossRefPubMedPubMedCentralGoogle Scholar
  74. 74.
    Tamler R, Dunn AS, Green DE, Skamagas M, Breen TL, Looker HC, et al. Effect of online diabetes training for hospitalists on inpatient glycaemia. Diabet Med. 2013;30(8):994–8.CrossRefPubMedGoogle Scholar
  75. 75.
    Tamler R, Green DE, Skamagas M, Breen TL, Lu K, Looker HC, et al. Durability of the effect of online diabetes training for medical residents on knowledge, confidence, and inpatient glycemia. J Diabetes. 2012;4(3):281–90.CrossRefPubMedGoogle Scholar
  76. 76.
    Tamler R, Green DE, Skamagas M, Breen TL, Looker HC, LeRoith D. Effect of case-based training for medical residents on confidence, knowledge, and management of inpatient glycemia. Postgrad Med. 2011;123(4):99–106.CrossRefPubMedGoogle Scholar
  77. 77.
    Wesorick DH, Grunawalt J, Kuhn L, Rogers MA, Gianchandani R. Effects of an educational program and a standardized insulin order form on glycemic outcomes in non-critically ill hospitalized patients. J Hosp Med. 2010;5(8):438–45.CrossRefPubMedGoogle Scholar
  78. 78.
    Selig PM, Popek V, Peebles KM. Minimizing hypoglycemia in the wake of a tight glycemic control protocol in hospitalized patients. J Nurs Care Qual. 2010;25(3):255–60.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  1. 1.Division of Endocrinology, Diabetes, and MetabolismUniversity of California, San DiegoSan DiegoUSA

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