Nurse-driven process reduces hypoglycemic episodes

Aug. 5, 2019
Study in Critical Care Nurse reports how a nurse-led initiative at Stamford Hospital reduced episodes of hypoglycemia, using a root cause analysis format

A nurse-directed initiative to examine the root causes of hypoglycemic episodes resulted in a sustained reduction in hypoglycemia among critically ill patients at Stamford Hospital in Connecticut, according to a study published in the August issue of Critical Care Nurse (CCN) and reported by the American Association of Critical Care Nurses.

Critical illness can cause blood glucose levels to fluctuate, making glycemic control a challenge in hospitalized patients. Even with frequent monitoring and patient assessments, the use of insulin therapy may result in lowering blood glucose levels too much.

Hypoglycemia, or blood glucose levels below 70 mg/dl, remains a common, and frequently preventable, patient safety concern, despite the development of evidence-based protocols and more informed guidelines for glycemic control. The Joint Commission recommends that all episodes of hypoglycemia be evaluated with a root cause analysis (RCA) to identify the underlying causes so the most effective solutions can be identified and implemented.

“Reducing Hypoglycemia in Critical Care Patients Using a Nurse-Driven Root Cause Analysis Process” reports how an interdisciplinary team at Stamford Hospital used the RCA approach to analyze in real time, each episode of hypoglycemia.

The nurse-driven RCA of hypoglycemic episodes resulted in a sustained reduction in hypoglycemia as well as improvement in other glucose metrics. Both the number of patients with and without diabetes who had a hypoglycemic event decreased, with corresponding decreases in the percentage of blood glucose values.

Co-author Sally O. Gerard, DNP, RN, CDE, CNL, is an inpatient diabetes educator at Stamford Hospital and an associate professor of nursing at Fairfield University, CT.

“By finding a process to drill down to a new level of detail regarding the variety of factors that can lead to hypoglycemia, nurses were able to examine their own practice and make relatively minor adjustments that produced positive results,” she said. “The model of nurse accountability for data collection and analysis represents the current culture of the expanding roles of bedside nurses.”

The RCA intervention encompassed 2,608 patients admitted over a 28-month period from Nov. 1, 2013, to Feb. 29, 2016. These patients were compared with a preintervention cohort of 2,429 patients. Both groups were then compared with a “continuation” cohort of 500 patients to determine the sustained effects of the intervention.

Nurses collaborated with the interdisciplinary team to develop a one-page RCA worksheet to evaluate more fully the conditions surrounding each hypoglycemic episode. The form documented individual risk factors, blood glucose levels before the event, relevant insulin administration, diet changes, nursing interventions and other factors that may have been related.

After a patient experienced a hypoglycemic event, the nurse completed the form, detailing episodes as they occurred. Monthly analysis of RCA forms allowed the staff to glean insights and identify commonalities.

The processes to prevent hypoglycemia that began during the RCA initiative were incorporated into the unit practices, and the improved data related to the project remained after the implementation phase.

In addition, the multiple approaches to glycemic control and safety allowed for additional glycemic metrics that supported positive patient outcomes, such as decreased mean blood glucose levels and glucose variability.