Authors: Emily Shor, PharmD and Alex Meyr, PharmDPGY1 Pharmacy Residents, SSM Health St. Mary’s Hospital – St. Louis
According to a report released by the Center for Disease Control and Prevention, over 100 million adults in the United States currently live with diabetes or prediabetes.1 Notably, various antidiabetic agents, such as insulin and secretagogues, are commonly associated with hypoglycemic events in the inpatient setting. Controlling both hyperglycemia and hypoglycemia is important in hospitalized patients and is associated with increased cost, length of stay, morbidity, and mortality.2 Association of hypoglycemia with mortality has resulted in changes in clinical guidelines which make recommendations regarding glycemic control.3
The 2019 American Diabetes Association guidelines defines level 1 hypoglycemia as a blood glucose < 70 mg/dL but > 54 mg/dL. A blood glucose of < 70 mg/dl is considered clinically important regardless of severity of hypoglycemia symptoms. Level 2 hypoglycemia is defined as blood glucose < 54 mg/dL and is associated with neuroglycopenic symptoms and requires action to resolve the hypoglycemic event.3
A retrospective review of hypoglycemic events (blood glucose < 50 mg/dL) in diabetes patients at SSM St. Mary’s Hospital St. Louis between June 2014 and October 2015 assessed a total 539 hypoglycemic events to identify the incidence of preventable recurrent hypoglycemic events before and after a collaboration between pharmacy and certified diabetic educators. This review determined that 7.5% of events that were reported pre-collaboration were preventable while 3.7% of events that occurred post-collaboration were preventable. Although this finding was not a statistically significant difference, it represents a nearly 50% reduction in events. The collaboration facilitated communication with the treatment team and thus therapeutic modification in an effort to prevent inpatient hypoglycemia. Through this project, SSM St. Mary’s Hospital pharmacy team developed a monitoring spreadsheet that allows for pharmacists to monitor hypoglycemia events and track interventions.
Since its development, the hypoglycemia monitoring spreadsheet has proven to be a useful tool that helps pharmacists identify potential causes for hypoglycemia as well as opportunities to prevent subsequent hypoglycemic events. Pharmacists run a report of any hypoglycemic events, defined by a blood glucose less than 50 mg/dL, which have occurred at St. Mary’s Hospital each day and then document the details regarding that event. Through this monitoring form, pharmacists intervene by contacting and communicating with providers to adjust the insulin regimen as well as determine if an event is considered preventable. These preventable events prove to be teaching moments for the entire pharmacy team to attempt to prevent these events from occurring repeatedly. At the end of each month, the list of hypoglycemic events is reviewed by the Medication Event Reporting Team (MERT), which consists of two pharmacy residents, two clinical pharmacy specialists, and pharmacy management. At these meetings, the nature of each event is discussed and whether or not they are truly preventable. Events considered preventable are reported so that other members of the healthcare team (including those specifically involved with the event) can have an opportunity to learn from the event and make necessary adjustments going forward. Additionally, the discussions during MERT meetings are presented to the rest of the pharmacy staff during weekly meetings as a means to further educate pharmacists about preventing hypoglycemic events (ideally aiming to have pharmacists take closer looks at insulin orders and not hesitating to clarify orders with physicians before verifying).
Although the hypoglycemia monitoring spreadsheet has been helpful in educating healthcare members about preventing events, there are still gaps in the monitoring form that have made it difficult for the MERT team and other pharmacists to truly learn from certain events. As a result, a new hypoglycemia monitoring spreadsheet was developed this year to help address some of these issues. Specifically, the old spreadsheet required pharmacists to document each specific event, even if it happened to the same person. This made it difficult to understand the full course of a patient’s hospital visit and determine if the multiple events a patient had were related (especially if the events were dispersed throughout the spreadsheet). Additionally, the original spreadsheet did not require pharmacists to input all of the necessary information needed to accurately assess the etiology and severity of a particular event. This resulted in significant variability among reports submitted by different pharmacists. There was a column that allowed pharmacists to provide a brief description of the event, but most pharmacists were not taking the time to document a full report of the event consistently.
The new hypoglycemic monitoring spreadsheet incorporates more columns in an effort to help pharmacists input more specific information regarding the event so the reported details are consistent and allow for easier interpretation by the MERT team. Furthermore, several drop down options were added to the spreadsheet to help make it convenient for pharmacists to document the information (i.e. drop down tabs for diet, type of insulin regimen, hypoglycemia management strategies). Additionally, the new spreadsheet included a section regarding recurrent events. This gives pharmacists an opportunity to simply add information to the same patient row as opposed to creating an entire new row and repetitive information if a different pharmacist had documented the event previously. By making this change, the MERT team was able to get a better understanding of the nature of various events and determine what specific factors contributed.
During the initial phases of implementing the new hypoglycemia spreadsheet, the pharmacists working with the spreadsheet most frequently identified a few barriers. Specifically, some pharmacists felt overwhelmed with the new form because it included several more columns than they were used to seeing. At a quick glance, the spreadsheet seemed like it would be more work and require more information to be documented. However, after some education and practice opportunities, pharmacists quickly realized that the process does not take much longer (some felt that it was quicker), and it allows for more detailed information to be provided.
Oftentimes, pharmacists find it challenging to identify the true cause of the hypoglycemic event. Additional research continues at SSM Health St. Mary’s Hospital to identify particular risk factors for hypoglycemic events. A recent review of hypoglycemic events between January 1, 2017 and June 1, 2017 found that almost half of the hypoglycemic events had documented PO intake and insulin administration mismatch. Additionally, patients’ home basal insulin dose was rarely decreased until a hypoglycemic event occurred. Based on the results of this review, pharmacists may consider recommending a reduction in home basal insulin doses by 20-30% or not exceed 0.3 units/kg for initial basal insulin doses inpatient.
The new hypoglycemia monitoring form has been implemented for over three months now, and the MERT team has already identified improvements in the monitoring process and the way in which pharmacists go about addressing insulin orders. Specifically, by inputting the required information in the spreadsheet, pharmacists seem to be more able and willing to provide a detailed description of a particular event. As a result, the MERT team is able to have more thorough discussions regarding events. This has led to more conversations among pharmacists and has helped make staff more vigilant with insulin orders. With more time implementing this new spreadsheet, data could be collected to see if there have been any reductions in the number of hypoglycemic events.