NORTHEAST OHIO VA HEALTHCARE SYSTEM BEST PRACTICE RECOGNITION/MANAGEMENT OF HYPOGLYCEMIA

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Jason Walsh
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1 NORTHEAST OHIO VA HEALTHCARE SYSTEM BEST PRACTICE RECOGNITION/MANAGEMENT OF HYPOGLYCEMIA Joint Commission Inpatient Diabetes Team Sharon A. Watts DNP, FNP-BC, CDE Drina Nemes MSN, CNS, CRRN Amanda Pensiero MD

2 Objectives: Learner will be able to: Define Hypoglycemia. Set safe blood glucose goals. Identify Hypoglycemia risk factors. Recognize the signs and symptoms of Hypoglycemia. Explain the rule.

3 Cleveland VA Inpatient Diabetes Certification The Northeast Ohio has maintained Joint Commission Inpatient Diabetes Certification since 2008 (an honor that only 1% of U.S. hospitals currently hold and no other VA Hospital!) and as such we need your commitment to uphold our diabetes standards. Our focus is on Veteran safety with early recognition, rapid management and prevention of hypoglycemia. We have a listing of our diabetes protocols and guidance for best care on the Pharmacy Website: Northeast Oho VA Healthcare Systems Pharmacy Website

4 What is Hypoglycemia? Hypoglycemia, or low blood glucose, occurs when the level of glucose in the blood drops below normal For many people with diabetes, that means a level of 70 milligrams per deciliter (mg/dl) or less Can be a side effect of insulin or other diabetes medications that cause the body to produce insulin U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. (2016.). Low Blood Glucose (Hypoglycemia) Retrieved from

5 Set Safe Blood Glucose Goals

6 The Lurking Dangers of Hypoglycemia

Safety Concerns Brodovich KG et al. Association between hypoglycemia and inpatient mortality and length of hospital stay in hospitalized, insulin-treated patients.

7 Safety Concerns Brodovich KG et al. Association between hypoglycemia and inpatient mortality and length of hospital stay in hospitalized, insulin-treated patients. Curr Med Res Opin. 2013;29(2): SALIBA, L; et al. Medication-induced and spontaneous hypoglycemia carry the same risk for hospital mortality in critically ill patients.

Serious Sequela of Hypoglycemia! More recent research over the past decade indicates that Hypoglycemia is not as benign as we thought in the past.

8 Serious Sequela of Hypoglycemia! More recent research over the past decade indicates that Hypoglycemia is not as benign as we thought in the past. Take a look at this potential list of Sequelae of Hypoglycemia: Serious Sequelae: Tachycardia Bradyarrhythmias ST Depression T-wave Flattening QT Prolongation Hypokalemia Severe Hypertension Falls Death

NICE Sugar Study Multi-site Inpatient ICU International Randomized Control Trial Conclusion: Mortality Increased by in tight 80-108 mg/dl glucose

9 NICE Sugar Study Multi-site Inpatient ICU International Randomized Control Trial Conclusion: Mortality Increased by in tight mg/dl glucose control group verses mg/dl in the conventional arm N Engl J Med Mar 26;360(13): doi: /NEJMoa Epub 2009 Mar 24

10 Risk Factors for Hypoglycemia Intensive glucose control/a1c targets Advanced age or cognitive impairment Low health literacy/numeracy Food insecurity (uncertain access to adequate food) Low economic status Prior hypoglycemic episode Hypoglycemia unawareness Liver/kidney disease Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes 2013;37(suppl 1):S1-S212.

11 Risk of Hypoglycemia by DM Medication TZD: Thiazolidinediones; DPP-4: Dipeptidyl peptidase-4; SGLT-2: Sodium-glucose cotransporter 2; GLP-1: Glucagon-like peptide-1 Diabetes Care 2017;40(Suppl. 1):S64 S74

Symptoms of Hypoglycemia Caution-signs/symptoms may be muted if on Beta-blocker therapy so err on the side of caution U.S. Department of Veterans Affairs (2016).

12 Symptoms of Hypoglycemia Caution-signs/symptoms may be muted if on Beta-blocker therapy so err on the side of caution U.S. Department of Veterans Affairs (2016). Hypoglycemia Safety Initiative. Retrieved from

13 Hypoglycemia Severity by Symptoms

14 Hypoglycemia Severity by Number Hypoglycemia < 70mg/dL Severe Hypoglycemia > 50mg/dL

15 15-15 Hypoglycemia Treatment Repeat

16 Avoid Possible Aspiration-Never Force Glucose into an Unconscious Patient s Mouth! If the patient is unable to swallow, or unable to receive treatment orally, (i.e., Nothing by Mouth (NPO) status) follow the protocol for the severe form of hypoglycemia.

See Northeast Ohio VA Healthcare System s Medical

17 Notify Provider for Repeated Hypoglycemia Insulin may need to be changed Data is collected to drive change See Northeast Ohio VA Healthcare System s Medical Center Policy Hypoglycemia Management: Link to MCP

18 Nurses-Remember to Chart Event!

19 Nursing Hypoglycemia Reference Card

20 Inpatient Hypoglycemia Nursing Competency For Inpatient Hypoglycemia Nursing Competency & other Diabetes Products: Office of Nursing Services Clinical Products Pagehttp://vaww.va.gov/nursing/cppP roducts.asp listed under Metabolic Syndrome & Diabetes----->View Products

Inpatient Management of Diabetes Mellitus. Jessica Garza, Pharm.D. PGY-1 Pharmacotherapy Resident TTUHSC School of Pharmacy

Inpatient Management of Diabetes Mellitus Jessica Garza, Pharm.D. PGY-1 Pharmacotherapy Resident TTUHSC School of Pharmacy 2 Disclosure Jessica Garza does not have any actual or potential conflicts of