Severe Hypoglycemia From Evidence to Practice: Guidelines and Policy Development

1. Severe HypoglycemiaFrom Evidence to Practice:Guidelines and Policy Development Alexis Farrington NUR 4745 Practice Pathways III Florida State College at Jacksonville Dr. Susan Shultz, DNP, CCRN, CNE

2. From Evidence to Practice:Preceptor • Tina Debile, BSN, PCCN (904)308-7300 Tina.Debile@stvincentshealth.com • Formerly, Clinical Resource Coordinator (CRC) at St. Vincent’s Medical Center for the fourth floor • Transitioning into new role as Coordinator of the new outpatient diabetes center

3. Clinical Focus • Tina’s specialty rests fundamentally in the area of diabetes education. • One of the many clinical areas on the fourth floor is management and treatment of diabetes events and crises. • Since December, 2010, multi-unit, random studies have been conducted in relationship to the management and revision of the hyper/hypoglycemia protocols.

4. This area was targeted to discover the most effective and efficient method to establish an evidence-based protocol in accordance with the facility’s policy that: Is nurse-friendly Limits additional documentation Manages and controls symptoms Promotes early identification of symptoms Prevents adverse events Functions within facility policy

5. PICOT QUESTION • In adult patients on medical-surgical units receiving subcutaneous insulin, does a nurse-driven hypoglycemic protocol in this population result in a reduction of hypoglycemic events compared to patients not treated without the use of a nurse-driven hypoglycemic protocol within a two to three month period of time? • P- Adult patients on medical-surgical, telemetry units receiving insulin subcutaneously • I – Nurse-driven hypoglycemic protocol • C- Patients not treated on a nurse-driven hypoglycemic protocol • O- Reduction of Hypoglycemic events • T- 2 to 3 months

6. LiteratureReview ADA & AACE Practice Guidelines • Revise and standardize therapeutic range based on specialization of clinical areas • Little documentation and research evidence to support any one given set of parameters for glucose management • “Glycemic targets of 80-100 is no longer considered appropriate for the critically ill population” (Reider, et. al., 2009). National Institute for Health and Clinical Excellence (NICE) • Performed to assess the level of prevalence associated with the fear of the development of hypoglycemia as a factor leading to negative outcome. • Unsafe self care: unsupervised adjustments in insulin dosing and alterations in dietary management. • Results: Although fear is a factor, it does not to contribute to the development of symptoms (Nixon & Pickup (2011).

7. Current Policy and Changes • Vincent’s Medical Center’s hypoglycemia protocol is currently under revision. • Previous protocol lacked specifics related to signs, symptoms and treatment modalities related to severe hypoglycemia. • Approved by physicians; however carried out by nurses. • Variances in outcomes and differences in perception regarding policy specifics induced the necessity of the construction of a nurse-guided policy. • Recent accomplishment was the release of the new emergency standing orders (ESO) protocol. St. Vincent’s Intranet (2011). Policies and Procedures.

8. Comparison to Policy The Evidence SVMC Policy Minimum baseline for treatment of hypoglycemia and subsequent symptoms at =/< 70. Allows more time for recognition of signs, symptoms and treatment targeted at prevention of an episode versus treatment of an event. Variances in outcomes (previous policy). • Leuven & Georgia Hospital Protocols (full and modified), presented in studies with an average baseline for the treatment of hypoglycemia at a minimum of =/< 50. • Variances in treatment time versus response to episode and symptoms. (Reider, J. D., 2009)

9. Results Data collected from ten patients with varying diagnoses • Not all of the patients were formerly diagnosed diabetics. • Four diabetics (one new onset and one pre-diabetic (pre-diagnosed). • There were two episodes of hypoglycemia occurring with minimal symptoms and both were treated with a minimum lapse in time of thirty minutes of the nurse’s knowledge of the occurrence. • All of the patients were scheduled to receive subcutaneous, slide scale insulin for glycemic maintenance.

10. Recommendations • Consider clinical status, collaborate and communicate for staff-friendly protocol. • Assess fundamental and clinical knowledge of nurses and support staff. • Simple tool for sign/symptom recognition based on the protocol implemented. • Educate staff, patients and families.

11. What Could Have Made the Study Better? Advantages Disadvantages Study time and duration limited to a few days Limited data to plot more specific event and evaluation over time Multiple co-morbidities associated with the cause of alterations in therapeutic levels • Diverse population of clinical scenarios • Access to majority of PMH • Multi-system effects of hypoglycemia and its causes • Quick access to current data • Witness response to episodes in real time • Increased ability to obtain feedback and responses from nurses regarding policy

12. Conclusion • Hypoglycemia, if untreated can cause significant irreversible neurological damage . • The evidence provided supports and confirms that early detection, monitoring and timely treatment is our first line of defense against the threat of severe symptoms. • Nurses provide the care and execute the orders that providers prescribe. • The creation of a nurse-driven protocol is ideal to: - Result in successful outcomes for our patients - Promote patient and family satisfaction of care - Maintain the preservation of confidence in our facility’s clinical performance - Reinforce competencies of our bedside nurses.

13. REFERENCES • Anabtawi, A. H. (2010). Incidence of Hypoglycemia with Tight Glycemic Control Protocols: A Comparative Study. Diabetes Technology & Therapeutics, 635-639. • Anthony, M. (2008). Hypoglycemia in hospitalized adults. Medical-Surgical Nursing, 1-9. • Buckingham, B. C. (2010). Prevention of Nocturnal Hypoglycemia Using Predictive Alarm Algorithms and Insulin Pump Suspension. Diabetes Care, 1013-1017. • Dean, S. S. (2010). Managing hypoglycemia: a descriptive analysis of current nursing practice. St. Vincent’s Health System Intranet Policies and Procedures. Retrieved March 10, 2011from Jaxhealth.com: http://www.jaxhealth.com • Nixon, R. P. (2011). Fear of Hypoglycemia in Type 1 Diabetes Managed by Continuous Subcutaneous Insulin Infusion: Is It Associated with Poor Glycemic Control. Diabetes Technology Therapeutics, 93-98. • Reider, J. D. (2009). Practical implications of the revised guidelines for inpatient glycemic control. American Association of Clinical Endocrinologists, 801-808.

14. St. Vincent’s Medical CenterJacksonvilleEmergency Standing Orders: Hypoglycemia Blood Glucose </= 70

15. Blood Glucose Value: 0-50 • Repeat blood glucose per bedside meter • Give 8 oz. apple juice or milk PO OR 50 mL D50 IV (If unable to swallow or NPO) • Repeat blood glucose per meter in 15 minutes & follow treatment protocol based on glucose result • Repeat blood glucose and treatment every 15 minutes until blood glucose is > 70 • Notify MD if glucose is < 70 after 3 treatments

16. Blood Glucose Value: 51-70 • Repeat blood glucose per bedside meter • Give 4 oz. apple juice or milk PO OR 25 mL D50 IV (if unable to swallow or NPO) • Notify MD, if not previously notified • Repeat blood glucose per meter in 15 minutes & follow treatment protocol based on glucose result • Repeat blood glucose and treatment every 15 minutes until glucose is > 70 • Notify MD if glucose is < 70 after 3 treatments

17. Blood Glucose Value </= 70(Patient does not have an IV line and cannot swallow) • Repeat blood glucose per bedside meter • Give 1 amp. (1 mg) glucagon IM STAT • Start IV and administer D5 ½ NS @ 60 mL/hr • Notify MD of glucose value and obtain further IV fluid orders • Repeat blood glucose per meter in 15 minutes & follow treatment protocol based on glucose result • Notify MD if glucose is < 70 after 3 treatments

18. Blood Glucose Value: </= 70(Patient is UNRESPONSIVE) • Repeat blood glucose per bedside meter • Give 50 mL of D50 IV STAT or 1 amp. (1 mg) of glucagon IM STAT (if no IV available) • Start IV and give D5 ½ NS @ 60 mL/hr • Notify MD of BG and obtain further IV fluid orders • Repeat glucose every 15 minutes until patient regains consciousness; then repeat blood glucose every 30 minutes unitl at least 2 consecutive levels are > 70 • Notify MD if glucose level is still < 70 after 3 treatments

19. Nursing Considerations & Responsibilities • All patients treated for hypoglycemia who are allowed PO intake must receive a meal OR 8 oz. milk AND 3 graham crackers OR 6 saltines within one hour of treatment. • NPO patients may require additional IV support after the hypoglycemic event: Consult MD for orders. • Document all signs, symptoms, treatment and response in nurse’s notes. • Document medications on MAR. • Document glucose values on flow sheet.