(CSEMP068) TREATMENT OF INPATIENT HYPOGLYCEMIA - CURRENT ISSUES AND QUALITY IMPROVEMENT OPPORTUNITIES

Abstract:

Background:
Inpatient hypoglycemia increases morbidity, mortality, and length of hospital stay (Carvalho, 2020; Lake, 2019). The Ottawa Hospital (TOH) inpatient hypoglycemia treatment protocol (juice if can drink or intravenous dextrose if unable to drink, and re-check in 15 minutes) was designed for diabetes mellitus (DM) inpatients when blood glucose (BG) is < 4 mmol/L, according to consensus guidelines (AMA, 2018; Yale, 2018). For inpatients without DM, hypoglycemia is considered BG less than ~ 3 mmol/L, and this protocol can also be applied. Electronic Medical Record auditing of hypoglycemia is an effective strategy for improving patient safety outcomes (Cruz, 2020).

Objectives:
To audit for adherence to the hypoglycemia protocol at TOH, and to inform quality improvement initiatives for timely resolution of inpatient hypoglycemia.

Methods:
Retrospective chart review for inpatients with point-of-care glucose meter reading < 4.0 mmol/L, from January to April 2021 at TOH. Characteristics collected for each event: DM status known or unknown, value of BG before and after treatment, capability to tolerate oral intake, whether hypoglycemia protocol was ordered, treatment given, time to BG re-check.

Results:
25% of BG < 4 mmol/L events occurred in patients with known DM and yet the hypoglycemia protocol was not ordered. In 59% of patients without known DM who had a BG < 4 mmol/L event, the hypoglycemia protocol had been ordered. While patients without DM are only considered hypoglycemic at BG < 3 mmol/L, inpatients without DM were treated with this hypoglycemia protocol for BG 3.1 to 3.9 mmol/L in 66% of cases.
The protocol’s treatment type was followed 74% of the time. However, 7% of BG < 4 mmol/L events received intravenous dextrose in a patient able to tolerate oral intake. 85% of blood glucose re-checks were delayed (over 15 minutes after initial event). 22% of BG re-checks exceeded 60 minutes after initial event. 20% of treated BG < 4 mmol/L events were unresolved on re-check.

Conclusions:
TOH hypoglycemia protocol is frequently not followed with regards to the intended population, treatment chosen, and BG re-checks. Future directions for optimizing inpatient hypoglycemia management to improve patient safety include analyses of barriers to appropriately ordering and following the hypoglycemia protocol through stakeholder focus groups. In addition, this study also reflects on the clinical effectiveness of this commonly used hypoglycemia protocol which had been based on small sample sizes, and may benefit from evaluation in the modern inpatient DM population (Brodows, 1984; Slama, 1990).