Protocol Cuts Hypoglycemia During Rehab

A hypoglycemia protocol for insulin-dependent diabetic patients in a rehabilitation hospital resulted in dramatic decreases in the need for rapid response team evaluations and transfers to acute care hospitals, researchers reported here.

During 2010, there were 24 episodes of hypoglycemic adverse events, seven (29%) of which required care by the rapid response team and six (25%) that led to transfer to an acute care hospital, according to Nitika Agarwal, PharmD, and Helen Afolarin, PharmD, of Marianjoy Rehabilitation Hospital in Wheaton, Ill.

During the nine months following implementation of a protocol to be initiated whenever a patient's blood glucose dropped below 70 mg/dL, there were 26 events, four (15%) with a rapid response team code but only one (4%) resulting in acute care facility transfer, the researchers reported in a poster session at the midyear clinical meeting of the American Society of Health-System Pharmacists.

Those outcomes represented a 48% decrease in rapid response team codes and an 84% decrease in acute care hospital transfers, they explained.

When patients with preceding diabetes are admitted to a rehabilitation facility following discharge from an acute care hospital for treatment of conditions such as stroke, surgery, or traumatic brain injury, they are at risk for hypoglycemia.

"What often happens is that when patients come to our facility, their insulin dosage isn't lowered even though they are eating solid food and being more active. As they receive rehabilitation, so they need less insulin," Agarwal explained to MedPage Today. "And in that circumstance, hypoglycemia can happen rapidly."

The researchers reviewed all hypoglycemia-related events, including the need for reversal agents, "code blue" events, rapid responses by teams comprising physicians, nurses, and others, such as respiratory therapists and hospital transfers.

Common reasons for these events included inappropriate managment of both hypo- and hyperglycemia, and delays in the administration of reversal agents because of gaps in knowledge, they found.

The formal management protocol provided directions for what steps must be taken, depending on whether the patient was conscious or not. Also, if the patient's blood glucose had normalized or remained below 70 mg/dL within 15 minutes after administration of juice, food, dextrose, or glucagon. The protocol was detailed on laminated cards and distributed to all clinical staff,

The result of the change in hospital practice was a marked decrease in serious insulin-related adverse events and improved patient safety.

The costs associated with transfer to acute-care hospitals also decreased, according to the researchers.

But despite these improvements, a high number of hypoglycemic events continued to occur.

"This could have several explanations, such as the occurrence of unexpected drug interactions, particularly among patients who are on multiple medications," Agarwal said.

However, the persistence of hypoglycemic events among patients requiring insulin could also relate to an increased awareness among staff of the signs and symptoms of hypoglycemia and more accurate reporting of events, she noted.

"We need to do further research to identify other areas for improvement in avoiding these preventable events," she said.