Hypoglycemia prevention and rapid treatment are key to patient safety, glycemic control and averting organ damage and mortality. In 2015, Nathan Littauer Hospital identified its most common adverse drug event as hypoglycemia secondary to insulin administration in the treatment of diabetes. In response, staff began a robust initiative to reduce these ADEs.
With strong senior level support, the hospital assembled a multidisciplinary team including hospitalists, pharmacists, dieticians, nurses, nurse educators and nurse informaticists. The team found that there was no standard physician order set or standardized practice available for the management of diabetes. A hypoglycemic treatment protocol was implemented, including documentation screens that allow for easy review and audit by the care team. Additional education was provided to all nursing staff and hospitalist team members across the institution. Current practice has a multidisciplinary team review all hypoglycemic events as they occur, whenever possible, or retrospectively to identify causes and possible opportunities for improvement or reeducation.
As a result of this initiative, hypoglycemic events were reduced by 87%. Furthermore, Nathan Littauer Hospital successfully developed and implemented a standardized prescriber order set and hypoglycemic protocol as well as a nurse-driven, anti-hypoglycemic protocol. The program has produced sustainable results, even throughout the COVID-19 pandemic, with zero hypoglycemic events experienced at the hospital over the past six months.
For more information, contact David Schaff, PharmD, CDE, director, pharmacy services, at firstname.lastname@example.org or 518.773.5425.