I N SP I R I NG CHANGE
Hypoglycemia prevention: An innovative approach By Sin Fan Se, MSN, BSN, RN, PCCN, and Kay Tucker, MSN, BSN, RN, CDE
AT OUR NONPROFIT community hospital, the multidisciplinary glycemic control committee is committed to providing the best care to patients with diabetes. One of the goals of our inpatient diabetes program is to reduce hypoglycemic events. The committee identified the need to sharpen and develop critical thinking skills in the management and prevention of hypoglycemia. A hypoglycemia audit tool was developed in paper form. The purpose of the tool was to increase awareness of signs and symptoms of hypoglycemia, possible cause(s), and treatment, and to stress the importance of alerting the primary medical team immediately when an event occurs. The ultimate goal was to improve nurses’ critical thinking skills and, at the same time, change patient treatment plans to decrease hypoglycemic events. This article will review the process of creating both a paper and electronic hypoglycemia audit tool and the results of its implementation. Patient safety goal According to the American Diabetes Association, hypoglycemia is a blood glucose level of 70 mg/dL or less. Knowing that mortality increases from unrecognized hypoglycemic events, hospitals are listing hypoglycemia awareness and prevention as a top patient safety goal.1 Early identification of patient-specific hypoglycemia causative factors is a strategy for preventing a patient’s blood glucose level from becoming critically low.2 Both The Joint Commission and the American Diabetes Association’s Standards of Medical Care in Diabetes recommend tracking and analyzing the
causes of hypoglycemia as an important quality improvement activity.3,4 Because glycemic management of a hospitalized patient is complex and depends on the interactions of numerous elements, a systems concept was used to develop and implement the hypoglycemia intervention flow sheet (HIF) designed to help reduce hypoglycemic events. Pilot study The glycemic control committee (composed of nurses, physicians, pharmacists, certified diabetes educators, dietitians, lab personnel, and quality consultants) conducted a gap analysis and identified the need to support hypoglycemia prevention. An additional gap analysis was performed by a clinical educator from April 2010 to September 2010. The analysis included a randomized patient medical record audit related to documentation. We discovered a lack of consistency in documentation of hypoglycemia signs and symptoms, contributing causes, treatment, treatment outcome(s), and physician notification. The committee initiated a plan for improving hypoglycemia management documentation with the goal of preventing hypoglycemia occurrence and reducing the severity of an event. This initiative brought changes in nursing documentation. In 2012, the committee took a multidisciplinary approach to develop an initial hypoglycemia audit tool (the HIF) that facilitated nurses’ ability to conduct an immediate analysis of the possible reasons for a hypoglycemic event. A clinical educator and clinical nurses conducted a 3-month pilot
study on our medical-renal unit to evaluate the meaningful use of the HIF. The study examined the relevancy of using the HIF and staff compliance. The clinical nurses on the medical-renal units were educated about the purpose and the use of the tool before the pilot study through slide presentations and discussion during the morning safety huddles. The clinical nurses were asked to complete an audit form for each hypoglycemic episode with comments or suggestions about the use of the tool. The completed audit tools were faxed to the glycemic control committee and temporarily filed in the patient’s chart until discharge. The glycemic control committee obtained laboratory records of all blood glucose levels below 70 mg/dL by glucometers on the medical-renal unit. Results indicated that the tool improved hypoglycemic event documentation and facilitated multiprofessional communication surrounding hypoglycemic events. The organizer of the pilot study obtained verbal feedback during the morning safety huddle and written comments and suggestions on the proposed hypoglycemia audit tool. Chart audits on documentation of hypoglycemia were done to verify the information on the completed tools. The multidisciplinary glycemic control committee analyzed the reported hypoglycemic events further based on the collected information on the completed tools. The pilot study participants felt more confident in critically analyzing and identifying patient-specific hypoglycemic causative factors. They stated that their advocacy for patient safety was enhanced by developing June l Nursing2015 l 19
www.Nursing2015.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
I N SP I R I NG CHANGE
hypoglycemia preventive measures collaboratively with other disciplines when the possible causative factors were immediately identified. By the end of the study, the nurses agreed that the tool was useful and meaningful. Participants also reported that the tool enhanced their ability to follow the hypoglycemia protocol. The protocol was modified to follow evidence-based guidelines and included using the Rule of 15, I.V. dextrose or glucagon, posttreatment blood glucose check, primary medical team notification, and hypoglycemia documentation. (See Rule of 15 for hypoglycemia.) One important benefit was that the tool facilitated early identification of the possible patient-specific hypoglycemia causative factors. The nurses in the study further simplified the initial HIF (audit tool) by modifying and removing sections to allow for a clear and concise format. For example, the section for listing current medications and the time of the last meal had been consistently left blank. The nurses stated that this information wasn’t immediately relevant to patient care and requested that it be deleted during the form modifications.
Gap analysis The nurses in the study and the glycemic control committee recognized the value of the HIF through the monitoring of its increased use. Numerous physicians commented that before the HIF was implemented, documentation of hypoglycemia occurrence and treatment wasn’t standardized. During the April 2011 gap analysis, the clinical educator audited patient medical records for the documentation of physician notification about hypoglycemic events. Results showed that 48% of the audited medical records lacked this documentation. A 2014 random audit of completed HIFs showed 100% documentation of physician notification. Subsequent documentation fostered verbal communication about the event and created opportunities for immediate treatment modification. The patient care directors and clinical educators noted increased recognition of the signs and symptoms of hypoglycemia. Early identification of the causative factors led to a decrease in the number of critical low blood glucose values and an overall reduction in hypoglycemic events. As a result of the pilot study’s success and
Rule of 15 for hypoglycemia • Consume 15 to 20 g of glucose or simple carbohydrates, such as – glucose tablets – two tablespoons of raisins – four ounces of juice or regular soda – one tablespoon of sugar, honey, or corn syrup – eight ounces of nonfat or 1% milk – hard candy, jelly beans, or gums drops (read the package label to determine how many equal 15 g). • Recheck blood glucose after 15 minutes. • Repeat the first two steps if hypoglycemia continues. • Eat a small snack (if the next meal is more than 1-2 hours away) after blood glucose is normal. REFERENCE 1. American Diabetes Association. Hypoglycemia (low blood glucose). 2014. http://www.diabetes.org/ living-with-diabetes/treatment-and-care/blood-glucose-control/hypoglycemia-low-blood.html.
the support of nursing administration, the HIF was implemented on all adult nongestational inpatient units. Since our initial gap analysis was performed after implementation of the tool, the rate of critical hypoglycemic events to noncritical hypoglycemic events has decreased from 15% to 6%. The secondary evaluation of the causative factors is aggregated and presented during the monthly glycemic committee meetings. Subsequently, plans of action are developed and implemented. It’s electric The greatest impediment to using the HIF was documentation on paper when everything else was done electronically. Therefore, an electronic HIF was developed in 2013 with the collaborative effort of the hospital’s clinical information system team and the glycemic control committee. The content of the electronic HIF was adapted from the paper version with some modifications. In order to stimulate critical thinking skills, we chose to list the common causative factors of hypoglycemia in the electronic HIF. 5 These include: change in insulin requirement, N.P.O. status, decrease in appetite, change in dietary status, renal disease, steroid taper, patient taken off the unit after receiving a dose of insulin, and delay in food distribution. The nurses can attach a note about any unusual causes of a hypoglycemia event to the HIF. One process that improved after identification of repeated hypoglycemic events was related to tray delivery. Through the collaboration of dietitians, food service, and nurses, the insulin dosing time was better coordinated with the tray delivery. The nurses are now notified of the meal tray arrival by the tray deliverers
20 l Nursing2015 l June
www.Nursing2015.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Root cause analysis from June to December 2013 Root cause
Steroid taper
Change in insulin
N.P.O.
Renal status
Unknown
Decreased appetite
Tray delay
Admitted with hypoglycemia
Off unit
June
2%
6%
28%
6%
42%
7%
2%
5%
3%
July
0%
11%
19%
2%
58%
3%
1%
4%
4%
August
0%
8%
39%
4%
39%
4%
1%
3%
3%
September
1%
13%
32%
5%
41%
4%
2%
0%
2%
October
1%
15%
15%
5%
44%
7%
2%
10%
1%
November
4%
10%
26%
6%
35%
8%
3%
6%
3%
December
0%
19%
30%
9%
31%
6%
1%
1%
3%
Average
1%
12%
27%
5%
42%
5%
2%
4%
3%
so insulin can be administered just before the patient eats. The technology team programmed rules and logic to help with decision support in the electronic HIF. When a glucometer reports a blood glucose level less than 70 mg/dL, the HIF immediately appears in the nurse’s workflow on his or her computer. This increases the nurses’ awareness of a low blood glucose level in real time and improves compliance with the documentation of causes and interventions. Additional data collection and continued analysis is now electronically available to the glycemic control committee for ongoing root cause analysis. A root cause analysis of the data collected from June to December, 2013 showed 42% of the hypoglycemic events had unknown causes and 27% of events were associated with N.P.O. status. (See Root cause analysis from June to December 2013.) A limiting factor of the current electronic HIF is the use of dropdown boxes instead of free text. The nurses use the “unknown” box if the cause isn’t specifically listed because they can’t write in the actual cause. Future modifications may either use a free text “other” box or list additional causes developed by the clinical nurses.
Staff compliance with completing the electronic HIF increased 2.5 times over the use of the paper form. Critical thinking also improved, as evidenced by the increased percentage of hypoglycemia causative factors identified. In only 24% of the audited hypoglycemia events from April 2010 to September 2010 had the hypoglycemia contributing factor been documented. The percentage of completed electronic HIF with identified contributing factor was 58% from June 2013 to December 2013. The increase of the documented contributing factors suggests that the nurses exercised better critical thinking in hypoglycemia management after the implementation of the tool. Technology improves communication The electronic HIF has improved patient care by: • reporting hypoglycemic events in an organized and timely manner. • promoting nurses’ critical thinking skills in hypoglycemia management and prevention. • facilitating a secondary root cause analysis of hypoglycemic events. • promoting clear communication to the primary care physicians about hypoglycemic events.
• helping clinicians develop preventive processes of care to decrease the incidence of hypoglycemia. • promoting consistency in physician notification and clinical documentation of any hypoglycemic event. The electronic HIF promotes clear communication to the primary medical team about hypoglycemia events. After reviewing the HIF, the primary care physician can make an appropriate clinical decision about adjusting medical treatments for patients with hypoglycemic events. The tool remains open on the RNs’ workflow screen until the posttreatment blood glucose value is recorded, so the effectiveness of the hypoglycemic intervention is consistently evaluated in a timely manner. The implementation of the electronic HIF also facilitates a secondary root cause analysis, which is important to identify hospital-wide performance improvement opportunities for better glycemic control. Improving outcomes Use of electronic health records (EHRs) in compliance with the Health Information Technology and Clinical Health Act will only increase as cybersecurity improves June l Nursing2015 l 21
www.Nursing2015.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
I N SP I R I NG CHANGE
and technologic advances grow. The use of the electronic HIF enhances compliance with EHR use. Improvements resulting from the use of the HIF include better compliance in following the protocol of hypoglycemia detection and prevention, and standardizing hypoglycemia event communication and documentation. Following the creation and implementation of the electronic HIF, the glycemic control committee also developed an electronic diabetes education needs assessment tool to help nurses assess patient education needs. This tool also serves as a guide for the nurses to perform patient teaching about diabetes management, which is important because prevention of hypoglycemia
and other diabetes complications result in lower readmission rates.6 The reported incidence of hypoglycemia in hospitalized patients ranges from 1.2% to 23%. Thanks to the HIF, our hospital’s current incidence of blood glucose levels below 70 mg/dL is less than 2%. This encourages us to believe that minimizing hypoglycemia is an attainable goal for our hospitalized patients with, or at risk for, diabetes. ■ REFERENCES 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):1153-1157. 2. Zhao Y, Campbell CR, Fonseca V, Shi L. Impact of hypoglycemia associated with antihyperglycemic medications on vascular risks in veterans with type 2 diabetes. Diabetes Care. 2012;35(5):1126-1132.
3. The Joint Commission. Joint Commission enhances inpatient diabetes advanced certification program. 2013. https://www.jointcommissionconnect.org/ NR/rdonlyres/BA48871B-4E04-45FE-AF73A8AF52B63E8F/0/JCP0813.pdf. 4. American Diabetes Association. Standards of medical care in diabetes—2015. http://professional. diabetes.org/admin/UserFiles/0%20-%20Sean/ Documents/January%20Supplement%20Combined_ Final.pdf. 5. Selig P, Popek V, Peebles K. Minimizing hypoglycemia in the wake of a tight glycemic control protocol in hospitalized patients. J Nurs Care Qual. 2010; 25(3):255-260. 6. Corl D, Guntrum P, Graf L, Suhr L, Thompson R, Wisse B. Inpatient diabetes education performed by staff nurses decreases readmission rates. AADE in Practice. 2015;3:19-23. At Virginia Hospital Center in Arlington, Va., Sin Fan Se is a clinical nurse educator and Kay Tucker is an inpatient diabetes program coordinator. The authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NURSE.0000464993.71477.b0
22 l Nursing2015 l June
www.Nursing2015.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Hypoglycemia prevention: An innovative approach By Sin Fan Se, MSN, BSN, RN, PCCN, and Kay Tucker, MSN, BSN, RN, CDE
AT OUR NONPROFIT community hospital, the multidisciplinary glycemic control committee is committed to providing the best care to patients with diabetes. One of the goals of our inpatient diabetes program is to reduce hypoglycemic events. The committee identified the need to sharpen and develop critical thinking skills in the management and prevention of hypoglycemia. A hypoglycemia audit tool was developed in paper form. The purpose of the tool was to increase awareness of signs and symptoms of hypoglycemia, possible cause(s), and treatment, and to stress the importance of alerting the primary medical team immediately when an event occurs. The ultimate goal was to improve nurses’ critical thinking skills and, at the same time, change patient treatment plans to decrease hypoglycemic events. This article will review the process of creating both a paper and electronic hypoglycemia audit tool and the results of its implementation. Patient safety goal According to the American Diabetes Association, hypoglycemia is a blood glucose level of 70 mg/dL or less. Knowing that mortality increases from unrecognized hypoglycemic events, hospitals are listing hypoglycemia awareness and prevention as a top patient safety goal.1 Early identification of patient-specific hypoglycemia causative factors is a strategy for preventing a patient’s blood glucose level from becoming critically low.2 Both The Joint Commission and the American Diabetes Association’s Standards of Medical Care in Diabetes recommend tracking and analyzing the
causes of hypoglycemia as an important quality improvement activity.3,4 Because glycemic management of a hospitalized patient is complex and depends on the interactions of numerous elements, a systems concept was used to develop and implement the hypoglycemia intervention flow sheet (HIF) designed to help reduce hypoglycemic events. Pilot study The glycemic control committee (composed of nurses, physicians, pharmacists, certified diabetes educators, dietitians, lab personnel, and quality consultants) conducted a gap analysis and identified the need to support hypoglycemia prevention. An additional gap analysis was performed by a clinical educator from April 2010 to September 2010. The analysis included a randomized patient medical record audit related to documentation. We discovered a lack of consistency in documentation of hypoglycemia signs and symptoms, contributing causes, treatment, treatment outcome(s), and physician notification. The committee initiated a plan for improving hypoglycemia management documentation with the goal of preventing hypoglycemia occurrence and reducing the severity of an event. This initiative brought changes in nursing documentation. In 2012, the committee took a multidisciplinary approach to develop an initial hypoglycemia audit tool (the HIF) that facilitated nurses’ ability to conduct an immediate analysis of the possible reasons for a hypoglycemic event. A clinical educator and clinical nurses conducted a 3-month pilot
study on our medical-renal unit to evaluate the meaningful use of the HIF. The study examined the relevancy of using the HIF and staff compliance. The clinical nurses on the medical-renal units were educated about the purpose and the use of the tool before the pilot study through slide presentations and discussion during the morning safety huddles. The clinical nurses were asked to complete an audit form for each hypoglycemic episode with comments or suggestions about the use of the tool. The completed audit tools were faxed to the glycemic control committee and temporarily filed in the patient’s chart until discharge. The glycemic control committee obtained laboratory records of all blood glucose levels below 70 mg/dL by glucometers on the medical-renal unit. Results indicated that the tool improved hypoglycemic event documentation and facilitated multiprofessional communication surrounding hypoglycemic events. The organizer of the pilot study obtained verbal feedback during the morning safety huddle and written comments and suggestions on the proposed hypoglycemia audit tool. Chart audits on documentation of hypoglycemia were done to verify the information on the completed tools. The multidisciplinary glycemic control committee analyzed the reported hypoglycemic events further based on the collected information on the completed tools. The pilot study participants felt more confident in critically analyzing and identifying patient-specific hypoglycemic causative factors. They stated that their advocacy for patient safety was enhanced by developing June l Nursing2015 l 19
www.Nursing2015.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
I N SP I R I NG CHANGE
hypoglycemia preventive measures collaboratively with other disciplines when the possible causative factors were immediately identified. By the end of the study, the nurses agreed that the tool was useful and meaningful. Participants also reported that the tool enhanced their ability to follow the hypoglycemia protocol. The protocol was modified to follow evidence-based guidelines and included using the Rule of 15, I.V. dextrose or glucagon, posttreatment blood glucose check, primary medical team notification, and hypoglycemia documentation. (See Rule of 15 for hypoglycemia.) One important benefit was that the tool facilitated early identification of the possible patient-specific hypoglycemia causative factors. The nurses in the study further simplified the initial HIF (audit tool) by modifying and removing sections to allow for a clear and concise format. For example, the section for listing current medications and the time of the last meal had been consistently left blank. The nurses stated that this information wasn’t immediately relevant to patient care and requested that it be deleted during the form modifications.
Gap analysis The nurses in the study and the glycemic control committee recognized the value of the HIF through the monitoring of its increased use. Numerous physicians commented that before the HIF was implemented, documentation of hypoglycemia occurrence and treatment wasn’t standardized. During the April 2011 gap analysis, the clinical educator audited patient medical records for the documentation of physician notification about hypoglycemic events. Results showed that 48% of the audited medical records lacked this documentation. A 2014 random audit of completed HIFs showed 100% documentation of physician notification. Subsequent documentation fostered verbal communication about the event and created opportunities for immediate treatment modification. The patient care directors and clinical educators noted increased recognition of the signs and symptoms of hypoglycemia. Early identification of the causative factors led to a decrease in the number of critical low blood glucose values and an overall reduction in hypoglycemic events. As a result of the pilot study’s success and
Rule of 15 for hypoglycemia • Consume 15 to 20 g of glucose or simple carbohydrates, such as – glucose tablets – two tablespoons of raisins – four ounces of juice or regular soda – one tablespoon of sugar, honey, or corn syrup – eight ounces of nonfat or 1% milk – hard candy, jelly beans, or gums drops (read the package label to determine how many equal 15 g). • Recheck blood glucose after 15 minutes. • Repeat the first two steps if hypoglycemia continues. • Eat a small snack (if the next meal is more than 1-2 hours away) after blood glucose is normal. REFERENCE 1. American Diabetes Association. Hypoglycemia (low blood glucose). 2014. http://www.diabetes.org/ living-with-diabetes/treatment-and-care/blood-glucose-control/hypoglycemia-low-blood.html.
the support of nursing administration, the HIF was implemented on all adult nongestational inpatient units. Since our initial gap analysis was performed after implementation of the tool, the rate of critical hypoglycemic events to noncritical hypoglycemic events has decreased from 15% to 6%. The secondary evaluation of the causative factors is aggregated and presented during the monthly glycemic committee meetings. Subsequently, plans of action are developed and implemented. It’s electric The greatest impediment to using the HIF was documentation on paper when everything else was done electronically. Therefore, an electronic HIF was developed in 2013 with the collaborative effort of the hospital’s clinical information system team and the glycemic control committee. The content of the electronic HIF was adapted from the paper version with some modifications. In order to stimulate critical thinking skills, we chose to list the common causative factors of hypoglycemia in the electronic HIF. 5 These include: change in insulin requirement, N.P.O. status, decrease in appetite, change in dietary status, renal disease, steroid taper, patient taken off the unit after receiving a dose of insulin, and delay in food distribution. The nurses can attach a note about any unusual causes of a hypoglycemia event to the HIF. One process that improved after identification of repeated hypoglycemic events was related to tray delivery. Through the collaboration of dietitians, food service, and nurses, the insulin dosing time was better coordinated with the tray delivery. The nurses are now notified of the meal tray arrival by the tray deliverers
20 l Nursing2015 l June
www.Nursing2015.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Root cause analysis from June to December 2013 Root cause
Steroid taper
Change in insulin
N.P.O.
Renal status
Unknown
Decreased appetite
Tray delay
Admitted with hypoglycemia
Off unit
June
2%
6%
28%
6%
42%
7%
2%
5%
3%
July
0%
11%
19%
2%
58%
3%
1%
4%
4%
August
0%
8%
39%
4%
39%
4%
1%
3%
3%
September
1%
13%
32%
5%
41%
4%
2%
0%
2%
October
1%
15%
15%
5%
44%
7%
2%
10%
1%
November
4%
10%
26%
6%
35%
8%
3%
6%
3%
December
0%
19%
30%
9%
31%
6%
1%
1%
3%
Average
1%
12%
27%
5%
42%
5%
2%
4%
3%
so insulin can be administered just before the patient eats. The technology team programmed rules and logic to help with decision support in the electronic HIF. When a glucometer reports a blood glucose level less than 70 mg/dL, the HIF immediately appears in the nurse’s workflow on his or her computer. This increases the nurses’ awareness of a low blood glucose level in real time and improves compliance with the documentation of causes and interventions. Additional data collection and continued analysis is now electronically available to the glycemic control committee for ongoing root cause analysis. A root cause analysis of the data collected from June to December, 2013 showed 42% of the hypoglycemic events had unknown causes and 27% of events were associated with N.P.O. status. (See Root cause analysis from June to December 2013.) A limiting factor of the current electronic HIF is the use of dropdown boxes instead of free text. The nurses use the “unknown” box if the cause isn’t specifically listed because they can’t write in the actual cause. Future modifications may either use a free text “other” box or list additional causes developed by the clinical nurses.
Staff compliance with completing the electronic HIF increased 2.5 times over the use of the paper form. Critical thinking also improved, as evidenced by the increased percentage of hypoglycemia causative factors identified. In only 24% of the audited hypoglycemia events from April 2010 to September 2010 had the hypoglycemia contributing factor been documented. The percentage of completed electronic HIF with identified contributing factor was 58% from June 2013 to December 2013. The increase of the documented contributing factors suggests that the nurses exercised better critical thinking in hypoglycemia management after the implementation of the tool. Technology improves communication The electronic HIF has improved patient care by: • reporting hypoglycemic events in an organized and timely manner. • promoting nurses’ critical thinking skills in hypoglycemia management and prevention. • facilitating a secondary root cause analysis of hypoglycemic events. • promoting clear communication to the primary care physicians about hypoglycemic events.
• helping clinicians develop preventive processes of care to decrease the incidence of hypoglycemia. • promoting consistency in physician notification and clinical documentation of any hypoglycemic event. The electronic HIF promotes clear communication to the primary medical team about hypoglycemia events. After reviewing the HIF, the primary care physician can make an appropriate clinical decision about adjusting medical treatments for patients with hypoglycemic events. The tool remains open on the RNs’ workflow screen until the posttreatment blood glucose value is recorded, so the effectiveness of the hypoglycemic intervention is consistently evaluated in a timely manner. The implementation of the electronic HIF also facilitates a secondary root cause analysis, which is important to identify hospital-wide performance improvement opportunities for better glycemic control. Improving outcomes Use of electronic health records (EHRs) in compliance with the Health Information Technology and Clinical Health Act will only increase as cybersecurity improves June l Nursing2015 l 21
www.Nursing2015.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
I N SP I R I NG CHANGE
and technologic advances grow. The use of the electronic HIF enhances compliance with EHR use. Improvements resulting from the use of the HIF include better compliance in following the protocol of hypoglycemia detection and prevention, and standardizing hypoglycemia event communication and documentation. Following the creation and implementation of the electronic HIF, the glycemic control committee also developed an electronic diabetes education needs assessment tool to help nurses assess patient education needs. This tool also serves as a guide for the nurses to perform patient teaching about diabetes management, which is important because prevention of hypoglycemia
and other diabetes complications result in lower readmission rates.6 The reported incidence of hypoglycemia in hospitalized patients ranges from 1.2% to 23%. Thanks to the HIF, our hospital’s current incidence of blood glucose levels below 70 mg/dL is less than 2%. This encourages us to believe that minimizing hypoglycemia is an attainable goal for our hospitalized patients with, or at risk for, diabetes. ■ REFERENCES 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):1153-1157. 2. Zhao Y, Campbell CR, Fonseca V, Shi L. Impact of hypoglycemia associated with antihyperglycemic medications on vascular risks in veterans with type 2 diabetes. Diabetes Care. 2012;35(5):1126-1132.
3. The Joint Commission. Joint Commission enhances inpatient diabetes advanced certification program. 2013. https://www.jointcommissionconnect.org/ NR/rdonlyres/BA48871B-4E04-45FE-AF73A8AF52B63E8F/0/JCP0813.pdf. 4. American Diabetes Association. Standards of medical care in diabetes—2015. http://professional. diabetes.org/admin/UserFiles/0%20-%20Sean/ Documents/January%20Supplement%20Combined_ Final.pdf. 5. Selig P, Popek V, Peebles K. Minimizing hypoglycemia in the wake of a tight glycemic control protocol in hospitalized patients. J Nurs Care Qual. 2010; 25(3):255-260. 6. Corl D, Guntrum P, Graf L, Suhr L, Thompson R, Wisse B. Inpatient diabetes education performed by staff nurses decreases readmission rates. AADE in Practice. 2015;3:19-23. At Virginia Hospital Center in Arlington, Va., Sin Fan Se is a clinical nurse educator and Kay Tucker is an inpatient diabetes program coordinator. The authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NURSE.0000464993.71477.b0
22 l Nursing2015 l June
www.Nursing2015.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
