From October to December 2018, Rush University Medical Center (RUMC) was experiencing an increase in hypoglycemic-related safety events across the organization. Due to this concern, the RUMC Patient Safety Department members began to review organizational efforts to improve the hypoglycemia rate within the organization and found multiple areas, including nursing, pharmacy and endocrinology, working on discipline-specific concerns. As a result, an inter-professional task force convened that could collaboratively work to improve the December 2018 organizational hypoglycemia rate of 2.03 percent.
The following opportunities were identified:
- improving workflow around meal delivery, point-of-care (POC) glucose and insulin administration
- monitoring POC glucose for high-risk patients
- implementing a nurse-driven basal-bolus protocol with proactive correction of hyperglycemia
- standardizing insulin administration instructions on MAR.
Blood glucose levels, insulin administration and meal delivery needed to be coordinated for effective treatment of diabetes. A subgroup of the hypoglycemic task force including clinical nurses, nursing leadership, endocrinology and dietary was developed and revised the workflow to support POC glucose checking timed around meal delivery.
Prior to workflow changes, the average time between POC glucose and mealtime insulin delivery was approximately 118 minutes for inpatient adults while evidence-based practice is less than 30 minutes. In August 2019, the new workflow was initiated and was able to reduce and maintain the time between POC glucose and mealtime insulin administration by over 30 minutes within the first week of workflow change.
Patient populations including patients with liver disease and diabetes who are nothing by mouth (NPO) are at higher risk of hypoglycemia. Monitoring POC glucose at regular intervals while NPO, and notifying provider if BG<70, can reduce hypoglycemia.
Rush implemented an evidenced-based protocol in September 2019 to improve blood glucose control for patients receiving insulin while hospitalized and reduce the incidence of hypoglycemia. Correction dose lispro scale is ordered at the same time as basal and prandial (mealtime) insulin regimen. Insulin administration instructions were standardized in the MAR to assist with consistency and the prevention of medication errors. This process change also contributed to lowering the time between POC glucose and insulin administration, as the provider is not required to place an additional order.
The hypoglycemia task force continues to meet monthly to review current practice and identify ways to improve patient safety and outcomes, and reduce hypoglycemia rates.