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Critical Hypoglycemia in Hospitalized Patients with Diabetes: Early Outcomes of Standardized Reporting and Management.

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Author Block: KATHERINE A. ARAQUE, DEEPAK KADAYAKKARA, NINO GIGAURI, KASIA J. LIPSKA, GREGORY BULLER, CLARE A. FLANNERY, Bridgeport, CT, New Haven, CT

Critical hypoglycemia (glucose <50 mg/dl) is associated with increased morbidity and mortality in hospitalized patients. We performed a root cause analysis of critical hypoglycemia events (HGE) on two inpatient medical wards with the highest incidence of HGE. Pre-intervention, management and reporting of HGE were inconsistent, and time from HGE to documented euglycemia (>100 mg/dl) was over 3 hours.

To reduce HGE incidence and improve the time from HGE to euglycemia, we initiated several system-based changes. The EPIC EMR was programmed to provide a standardized order set for basal-bolus insulin regimen, automated dextrose order for all HGE (gel or IV), automated MD notification, and recommendation for Endocrine consultation after 2 critical HGE. The Pyxis Med Station was programmed to alert nurses to recheck blood glucose 15 minutes after dextrose. A card with the HGE management protocol was attached to each provider’s ID badge, and educational seminars were given to all providers on the 2 inpatient wards. Pre- and post-intervention events (Table 1) were analyzed by 2-tailed Mann Whitney U and Chi-square tests. A marked improvement in the incidence of HGE and time to recovery demonstrate the positive impact of these system-based interventions. These interventions were expanded to the entire hospital and can be potentially applied to other hospitals to improve patient safety.Table 1:

Outcomes of HGE management pre- and post interventionsPre-Intervention (duration 3 months)Post-Intervention (duration 6 months)p-valueCo-Primary Outcome: Time from HGE to euglycemia (median +/- SD)225 ± 46 min87 ± 26 min0.03Co-Primary outcome: Time from HGE to next fingerstick (median +/- SD)76 ± 14 min28 ± 10 min<0.001

Secondary Outcome: Incidence of HGE (number of HGE per total ward admissions with DM)11 per 100 admissions (35/320)5.6 per 100 admissions

(37/653)<0.001Recurrent HGE (glucose<50 mg/dl more than once on a given patient)37% (13/35)24% (9/37)0.09Documented Treatment of HGE63% (22/35)97% (36/37)<0.001Physician Notification51.4% (18/35)78% (29/37)<0.001

Authors: KATHERINE AARAQUE, DEEPAK KADAYAKKARA, NINO GIGAURI, KASIA J. LIPSKA, GREGORY BULLER, CLARE A. FLANNERY, BridgeportCT,  New HavenCT

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