How Low Can You Go? Reducing Rates of Hypoglycemia in the Non-critical Care Hospital Setting
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Purpose of Review
The purpose of this review is to discuss strategies to reduce rates of hypoglycemia in the non-critical care setting.
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.
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.
KeywordsHypoglycemia Diabetes Insulin Inpatient Hospital Non-critical care
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.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 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
- 8.Analytics) PATH, Analytics) WLTH, (AHRQ) SC. Costs for Hospital Stays in the United States Rockville, MD2011.Google Scholar
- 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.
- 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.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.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.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.CMS/The Joint Commission. NQF-endorsed voluntary consensus standards for hospital care. Surgical care improvement project. 2014.Google Scholar
- 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.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.
- 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.Arem R. Hypoglycemia associated with renal failure. Endocrinol Metab Clin N Am. 1989;18(1):103–21.Google Scholar
- 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
- 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
- 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.
- 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
- 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/.
- 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
- 72.Ellis R. Hypoglycaemia monitoring in a medical receiving ward. BMJ Qual Improv Rep. 2015;4(1)Google Scholar