Inpatient hypoglycaemia: the continuing problem and need for a proactive management protocol
Cassandra Sobajo & Prasanna Rao-Balakrishna
Hypoglycaemia is defined as capillary blood glucose (CBG) of ≤4 mmol/l irrespective of symptoms. We audited the recognition and management of inpatient hypoglycaemia with a view to identify potential areas for improvement.
Methods: A total of 120 inpatients with diabetes were identified in the hospital on a single day, of whom n=32 had ≥1 episode(s) of hypoglycaemia, as evidenced by their CBG. Data relating to recognition and management of the event(s) by the nursing/medical staff was collected from 79 hypoglycaemic events in total.
Results: The frontline staff failed to recognise hypoglycaemia in n=10 (31% of 32); and only 34% of the initial and 25% of the subsequent management was appropriate. Recurrent hypoglycaemia was more likely to be recognised (100% at >5 events) and better managed. Assessment of response to initial treatment was preformed in only 6%. Hypoglycaemia was rarely documented in medical notes; only 3% with one event and 13% with ≥4 events had both medical/nursing documentations. Medication reassessment and dose titration was least likely in those with single events (19 vs 50%). Referral to the diabetes team was made only in a quarter.
Discussion: The audit highlights the problems associated with recognition and management of hypoglycaemia by frontline nursing staff. Delayed recognition of the low CBG as hypoglycaemia resulted in inadequate initial management. Insufficient documentation in nursing/medical notes led to delays in the reassessment of regular hypoglycaemic agents, recurrences of hypoglycaemia and lack of referral to the inpatient-diabetes team. Literature suggests prolonged hospital stay and increased mortality with inpatient hypoglycaemia1. Appropriate action is therefore necessary to prevent hypoglycaemia whilst achieving good inpatient glycaemic control. New hypoglycaemia management guidelines with standardised documentation sheets addressing these issues have been drawn-up and rolled out.
1. Turchin A, Matheny ME, Shubina M, Scanlon JV, Greenwood B & Pendergrass ML. Hypoglycaemia and clinical outcomes in patients with diabetes hospitalized in the general ward. Diabetes Care 2009 32 (7) 11531157.