Hypoglycemia Prevention in Hospital Patients: A Quality Improvement Project to Prevent Severe and Recurrent Hypoglycemia.

Abstract

Hypoglycemia, defined as a blood glucose level <70 mg/dL (3.9 mmol/L), occurs frequently in hospitalized patients. Both inpatient and outpatient trials have shown that the risk of hypoglycemia limits the achievement of blood glucose control (1–7). In addition to causing distress for patients, severe hypoglycemia is associated with cardiac arrhythmias, cardiac ischemia, seizures, brain damage, and death (3,4,8–12). After a hypoglycemic event, the likelihood of further episodes of low blood glucose is increased (2,9,12,13). Glycemic variability is also independently associated with risk of mortality (5–9,12,14,15) and can be an unintended consequence of reactive treatment of hypoglycemia. If dextrose is given only in response to low blood glucose levels, but the precipitating factor for hypoglycemia persists, a cycle of recurrent low glucose levels alternating with higher post-treatment levels occurs. Fortunately, this pattern represents a modifiable risk, as illustrated in Figure 1 (14). FIGURE 1. Recurrent hypoglycemia: treatment versus prevention. Initially hypoglycemia was treated reactively, with at least five recurrences of low blood glucose and high glycemic variability. With initiation of proactive IV dextrose, further hypoglycemia was prevented, and glycemic variability was reduced. Recent advances in health care quality and patient safety call for a change from reactive to preventive care. When this concept is applied to hypoglycemia management, it is evident that the unevaluated assumption that reactive treatment of hypoglycemia is sufficient often underlies facility routines. Avoiding circumstances that are frequently associated with low blood glucose levels is at the core of optimal glycemic management in the inpatient setting. Recent studies show that “safe and effective glucose control” (15) can be facilitated and hypoglycemia can be prevented through tactics such as appropriate monitoring, ensuring adequate caloric intake, coordinating the …