A road map to severe hypoglycemia reduction in hospital patients

BJC HealthCare, a large healthcare system in St. Louis, MO, designed and implemented a data-driven and evidence-based approach to drive down the number of severe hypoglycemia cases in hospitalized patients over a five-year period, according to a report in the American Journal of Health-System Pharmacy.

Drug-induced hyperglycemia and hypoglycemia, nonprescription medications, and complementary alternative medicine for diabetes

Paul E. Milligan, PharmD, the medication safety pharmacist at BJC HealthCare, and colleagues, outlined a road map to address severe hypoglycemia, which has been shown to increase the length of hospital stays and mortality. From 2009 to 2014 the rate of severe hypoglycemia events plunged from 6.45 per 1000 patient-days at baseline to 1.32 per 1000 patients days after implementation of the initiative. At the 11 facilities, there was a reduction in severe hypoglycemia events that ranged from 70% to 100%.

Taskforce creation

In 2010 at their health system, including nine community and two academic hospitals, a taskforce, led by a pharmacist, was developed and included certified diabetes, clinical nurses, endocrinologists, dieticians, epidemiologists, pharmacists, informatics specialists, and a physician, which worked to create similar multidisciplinary teams at each of their individual facilities.

1) Dashboards

 “One of the first steps taken by the Hypoglycemia Task Force was to develop dashboards to display monthly progress, raise awareness, and garner leadership support,” wrote Milligan and his colleagues. “In addition, to bring this concern to the forefront, severe hypoglycemia events were added to BJC’s systemwide quality scorecard beginning in 2011.”

To ensure that the data displayed in the dashboards could be compared fairly among the different facilities, the task force created a hypoglycemia at-risk rate-taking the number of severe hypoglycemia events at each hospital and dividing it into the number of inpatient days for any patient prescribed an antidiabetic agent.

“We identified hospitals with the lowest event rates for site visits to guide the initial development of foundational best practices while targeting hospitals with the highest rates for early improvement initiatives,” the authors noted.

2) Evidence-based best practices

As a foundation, the task force started with the recommendations of the 2009 joint American Association of Clinical Endocrinologists–American Diabetes Association consensus statement about inpatient glycemic control. They also reached out to other healthcare professionals, including pharmacists, for their input, and gathered other best practices from the higher performing facilities within the BJC HealthCare system.

Some best practices included that insulin only be withheld in the case of a prescriber’s order, a 30% reduction in sliding-scale insulin dose at bedtime, instructions to avoid routine use of correction insulin at 2 am and 4 am, and that prescribers are notified if the patient has a blood glucose level reading <50 mg/dL or two blood glucose level readings <70 mg/dL.

3) An online hypoglycemia event analysis tool

The task force developed the Hypoglycemic Event Analysis Tool (HEAT) to discover the cause of severe hypoglycemia events and then to follow up with investigation. At first BJC HealthCare used a paper tracking system, which were completed within 10 days of the event by diabetes educators, nurses, or pharmacists. A clinician would then determine the cause from a predetermined list.

“During the original phase of data collection, in 2011-2012, the three most frequently identified causative factors (as described on the predefined list) were ‘timing issues,’ ‘glucose trend not recognized,’ and ‘home regimen continued as inpatient,’ ” the authors wrote. “The list of causative factors continues to be reevaluated and updated to address newly identified concerns.”

4) An online hypoglycemia tracking site

To use the information gathered from the HEAT and learn from the successes of the different facilities, an interactive website was created-Hypoglycemia Facility Strategy Tracking (H-FaST).

“The site provides a monthly updated prioritization of causative factors for each hospital, with links to factor-specific task force recommendations,” explained Milligan and his colleagues. “Local hospitals were able to identify which other hospitals had implemented the recommendations and easily request information regarding successes and challenges.”

The authors noted that the tools that were developed for this initiative are being used for the reduction of other serious adverse drug events in BJC HealthCare facilities, such as severe hyperglycemia and diabetic ketoacidosis.

“We encourage other hospitals and health systems to adopt and implement the HEAT and begin systematically collecting and sharing information on causative factors,” Milligan and his colleagues wrote.