Hypoglycemia, defined as blood glucose levels less than 70, is associated with increased mortality and adverse effects such as confusion, seizures, loss of consciousness or coma. Zesati knew that most hypoglycemic events are preventable in the inpatient setting.

A series of chart audits led her to focus on three key goals for improvement:

• Align the hypoglycemia management order set and available tools with current professional guidelines.
• Support nurses’ knowledge of hypoglycemia management.
• Revise the documentation process for hypoglycemic events.

Guided by this information, Zesati collaborated with pharmacists, physicians, a registered dietitian (RD) and informaticists from the Glycemic Control Committee to review and revise the current hypoglycemia management order set and other related processes.

Revising the Order Set and Supporting Tools

Zesati; Nicolas Kissell, MD; Mark Danek, PharmD; Shaun Manuel, PharmD; Jill Crowley, MS, RD; Chief Medical Information Officer David Kasting, MD; and informaticists from the medical center’s Glycemic Control Committee reviewed and revised the current hypoglycemia management order set and other related processes, with input from physicians and nurses. The resulting evidence-based interventions included:

• Streamlining the hypoglycemia policy and adding current evidence-based hypoglycemia treatment recommendations from The American Diabetes Association and Centers for Disease Control and Prevention
• Gaining approval for an updated order set from both the Glycemic Control Committee and Pharmacy and Therapeutics Committee
• Updating EndoTool, the medical center’s software program for dosing and titrating insulin drips for patients with diabetes

Educating Nurses, Improving Documentation

To update the nursing staff, Zesati worked with nurse educator Charvelle Noble, BSN, RN, CMSRN, to develop a program that Zesati presented at RN Skills Day events in the spring of 2022. The program drew on key components of the collaborative plan of care for preventing hypoglycemic events, including:

• The new order set and EndoTool updates
• Appropriate diet orders, including for more complex patients
• Patient education support available to nurses or physicians via a consultation with the diabetic nurse navigator and/or the registered dietitian
• How to coordinate insulin coverage with meals and adjust insulin dosing orders
• Prevention of duplicate medical orders

“We also created a version of this program for the new graduate nurses’ orientation program, which focused especially on preventing hypoglycemic events, including reminders about communicating with dietary to coordinate insulin administration and when to communicate with the physician,” Zesati says.

Finally, Zesati worked with informatics and the Glycemic Control Committee to develop a hypoglycemic intervention documentation screen for the electronic medical record. The changes enabled her to more easily share hypoglycemic event data at Glycemic Control Committee meetings to enhance the monitoring of hypoglycemic issues and help identify and address systemic issues.

All the interventions were in place by September 2022. “By December, the rates of hypoglycemic events in admitted patients with diabetes over the age of 14 were reduced by nearly two-thirds, to 7.7%, which is an inspiring testament to the power of collaboration,” Zesati says.