Hypoglycaemia Management in Adult Inpatients with Diabetes - - PowerPoint PPT Presentation

An Audit of Hypoglycaemia Management in Adult Inpatients with Diabetes

Presented by: Brett Fenton, NUM Diabetes Services Prepared with: Julie Droguett, CNS 2 Diabetes Services

Background and Rationale

Gosford and Wyong Hospital combined have approximately 800 beds Hypoglycaemia is defined BGL <4.0 mmol/L For each day with hypoglycaemia, patients’ length of stay (LOS) is increased by 2.5 days¹ Approximately 23% of inpatients with diabetes experience hypoglycaemia at least once during their stay²

Aim and Objective

Several hypoglycaemia incidents prompted the need to investigate: a) Frequency of hypoglycaemia events in the acute care setting b) Does management match current evidence based guidelines.

Methodology

 Demographic: age, gender, diabetes type and duration  Reason of admission and co-morbidities  Medication (insulin and/or sulfonylureas)  Number and severity of hypoglycaemia episodes  Documentation on bed chart and progress notes  Follow-up and ongoing management e.g. medication reviewed and adjusted?  Was blood glucose level re-tested 15 minutes later?  Treatment administered?

Table 1: Demographic data

Total patients Patients with Diabetes Patients Insulin/ Sulfonylureas Patients with Hypos

Total

489 89 52 29 (56%)

Gender

M=230; F=255; Missing=4 M=42; F=46; (Missing=1) M=27; F=25 M=16; F=13

Age (years)

69.9 71.5 +/- 14.9

(Range: 18 – 93)

70.5 +/- 15.2

(Range: 22 – 93)

72.7 +/- 14.7

(Range: 37 – 90)

Av LOS (days)

n/a 21.2 +/- 18.4

(Range: 2 – 94)

22.3 +/- 18.0

(Range: 2 – 63)

26.2 +/- 17.5 (Range: 5 – 63) Diabetes Duration (years)

n/a 19.0 +/- 14.2

(Range: 0.5 – 49) (Missing=68)

21.8 +/- 14.1

(Range: 3 – 49) (Missing=35)

25.9 +/- 13.7

(Range: 5 – 49)

(Missing n= 17)

Results

 205 hypoglycaemic episodes were documented among 29 patients.  14 episodes were from sulfonylureas alone  15 episodes were severe with a BGL <2.0 mmol/L  Only 18/205 (9%) episodes were rechecked within 15 mins, (range 5 mins - >24hrs, avg 116 mins)  2/3 of documented treatment was incorrect

Results

 69 (34%) episodes had no documented treatment  Hypoglycaemia managed poorly for people with Insulin infusions  Diabetes history poorly documented, 20% did not state diabetes type and 76% did not state duration  10% of all IIMS in our LHD for medications are related to insulin

Case Study: AH, T2 Diabetes

 Admitted with cellulitis, previous cardiac history, 2 medical wards during admission of 39 days  Insulin was withheld on 10 occasions, 12 missed doses, 27 stat doses  33 hypoglycaemic episodes recorded, 12 did not receive any documented treatment, only 8/33 were retested within 15 minutes, 5 recorded under 2.0 mmol/L  Insulin Infusion – tx not as procedure

Recommendations and Actions

 Review and promote Diabetes procedures  Mandatory diabetes education for all Nurses  Nurse Managers to promote documentation/treatment of hypos, & ensure Hypo kit on ward is checked daily  Diabetes Educator for Gosford & Wyong Hospitals  Diabetes Inpatient Working Party  Clinical Directors Recommend: Medical assessment on admission and identify type of diabetes and risk of hypoglycaemia

HYPO KIT Not if patient is unconscious or unable to swallow.

Conclusion

 The audit reveals that, in the majority of cases, procedures for hypoglycaemia management were not being followed. Staff knowledge regarding Hypoglycaemia management was poor  There is an increased awareness of Diabetes and a better understanding of the importance of Diabetes Educators  Plan to re-audit in 2016 – to evaluate the success of implementing recommendations

References



• 1. Turchin A, Matheny ME, Shubina M, Scanlon JV, Greenwood B, Pendergrass ML (2009)

Hypoglycemia and clinical outcomes in patients with diabetes hospitalized in the general ward. Diabetes Care 32(7): 1153–1157. 

• 2. Fourlanos S, Elkassaby S, Nanayakkara N, Marijanovic N, Nankervis A, Colman PG (2013) Inpatient

diabetes audit identifies frequent diabetes medication errors and suboptimal glycaemia (Ab87). Melbourne Health Research Week. Melbourne, Vic. 23-30 May 2013. 

• 3. NSLHD Diabetes Educator Network (2009). PR2009_362: Hypoglycaemia - Northern Sydney Central

Coast NSW Health. [accessed 12/02/13] http://intranet.nslhd.health.nsw.gov.au/AreaGov/NSGovSys/AreaPPGLibrary/Medicine/Endocrinology/P R2009_362.pdf 

• 4. Droguett J, King J, Fenton, B (2014) Project Report: An audit of hypoglycaemia management of adult

in-patients with diabetes. 

• 5. Thompson C, Fenton B (2014) PR2014_017 Hypoglycaemia: Recognition and Treatment for Adults

with Diabetes. [accessed 02/07/14] http://intranet.cclhd.health.nsw.gov.au/ppg/PPGLibrary/Medicine/Endocrinology%20Diabetes/PR2014_0 17.pdf 

• 6. Matteson S, & Droguett J. (2014) PR2009_359: Insulin Infusion for the management of

Hyperglycaemia in adults [accessed 12/2/2014] http://intranet.nslhd.health.nsw.gov.au/AreaGov/NSGovSys/AreaPPGLibrary/Medicine/Endocrinology/P R2009 359pdf.