Reducing Inpatient Hypoglycemia: A Diversified Approach to a Complex Problem.

Objective: Hypoglycemia in hospitalized patients is a persistent adverse event. Three quality improvement interventions were implemented with the aim of reducing hypoglycemia. Each intervention was targeted at one component of typical inpatient insulin management (basal, prandial, and correction) to attempt to achieve this singular quality improvement aim.

Methods: Incidence of hypoglycemia in non-obstetrics patients ≥ 19 years of age at a tertiary hospital receiving scheduled insulin before and after the implementation of quality improvement initiatives was compared. Incidence was defined as the number of unique patients with a hypoglycemic event in each month, divided by all admissions for that month. The interventions included integrating weight-based insulin guidance into the electronic medical record (EMR), the addition of a carbohydrate-limited diet, and increasing the threshold for correction insulin administration from 150 mg/dL to 180 mg/dL.

Results: After implementation of the interventions, there was a significantly lower incidence of hypoglycemia associated with prandial insulin (p = 0.02) and correction insulin (p < 0.001). There was not a significant decrease in hypoglycemia associated with basal insulin in the overall sample (p =0.25). There was a significant decrease in a subgroup analysis focused on hospital-associated hyperglycemia and type 2 diabetes (via exclusion of patients with type 1 diabetes or cystic fibrosis-related diabetes) (p = 0.005). Notably, following the interventions, there was a reduction in institutional blood glucose readings within goal range (71-179 mg/dL), which presumably translates to an increase in hyperglycemia given the known decrease in hypoglycemia (p value <0.0001).

Conclusion: Through a multipronged approach consisting of three unique QI interventions - each targeting one aspect of inpatient insulin management - our academic institution was able to significantly reduce the number of inpatient hypoglycemic events.