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We performed a 130-patient case-control study to examine the patient and hospital care risk factors for experiencing a hypoglycemic patient-day, comparing these factors to similar control patients who were not experiencing a hypoglycemic patient-day. We also examined adherence to our hypoglycemia management protocols, documentation of the event, and adjustments to medications and nutritional regimens that occurred in response to the hypoglycemic event. The most powerful risk factors for hypoglycemia were unexpected nutritional interruption, prior hypoglycemia during the hospital stay, and asynchrony of nutrition delivery and insulin administration. Adherence to hypoglycemia management and documentation standards was poor. Here, we outline strategies to focus improvement efforts on adherence to hypoglycemia treatment protocols and proactive management of patients with these key hypoglycemia risk factors.
Diabetes has become an increasingly common comorbid condition in acute care settings in the United States.1,2 Guidelines advocating near-euglycemic targets have been published and widely promoted,34 but improvement often proves difficult. Hypoglycemia is the most prominent limiting factor in the glycemic management of type 1 and type 2 diabetes.5,6 Fear of hypoglycemia often leads to clinical inertia,7,8 with attendant nontreatment of potentially harmful hyperglycemia and a reliance on sliding-scale insulin regimens.9 This faulty approach persists in spite of randomized trials demonstrating that physiological (basal-bolus) subcutaneous insulin regimens can achieve improved glycemic control without increasing the frequency of hypoglycemic events.10
Although fear of hypoglycemia remains a barrier to inpatient glycémie control efforts, there is a paradoxically uneven approach to the treatment of iatrogenic hypoglycemia and methods to prevent it. Recent literature highlights poor adherence to hypoglycemia treatment and documentation standards.11,12 Failures to adjust anti-hyperglycemic medication appropriately for sudden loss of caloric exposure or to prevent a recurrent hypoglycemic event are common in both nursing and physician staff, and known risk factors for hypoglycemia are not identified or not acted on.11,13,14 Hypoglycemic excursions on medical/surgical wards by methods other than ignoring glycemic control may be preventable as the rule, rather than the exception.15 More than 40% of patients experiencing one iatrogenic episode go on to suffer from at least one additional distinct hypoglycemic event, and these recurrent events also appear to be largely preventable.11,16
In 2004, our medical center formed a multidisciplinary glycemic control steering committee and developed "glucometrics" to describe insulin use patterns,...