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Inpatient hypoglycaemia: a study of nursing management.

In New Zealand, diabetes has been described as reaching epidemic status (Berkley & Lunt, 2006). The prevalence of Type 2 diabetes was predicted to increase from 123,944 people (3.2% of population) in 2001 to 194,380 (4.5% of population) in 2011 (Ministry Of Health, 2007). By 2012, 200,000 (5%) of New Zealand adults had been diagnosed with diabetes (Ministry of Health, 2012a). Diabetes is a significant cause of mortality in New Zealanders, and resulted in 869 deaths per 100,000 people during 2009 (Ministry of Health, 2012b).

Diabetes is the most commonly identified comorbidity in people admitted to hospital (Barnabas, Javed, Javed, & Kaushal, 2010). In Northland during 2005, 5% of all inpatients had diabetes and they used 21% of all the bed days (Northland District Health Board, 2006). Patients with diabetes have complex health care needs in the hospital setting and may experience prolonged lengths of stay and increased rates of inpatient infection, disability and mortality (Moghissi et al., 2009). Whilst tight glycaemic control has been advocated for the Intensive Care Unit (ICU) patient for some time, good metabolic control is now also recommended for all patients with diabetes in the non-ICU context as a means to improve clinical outcomes (American Diabetes Association, 2006; Turchin et al., 2009).

Hypoglycaemia is known to be common amongst inpatients. The 2007 study by Cagiliero, Grant, Meigs, Nathan and Wexler of 999 patients admitted to 44 hospitals across the United States of America found hypoglycaemia occurred in 12-18% of cases. One of largest studies (n=2,582) of inpatient hypoglycaemia undertaken to date also in the United States, identified that mortality during admission in patients who had at least one episode was 2.96% compared with 0.82% for patients who did not develop hypoglycaemia. Inpatient mortality increased dramatically with each additional day that hypoglycaemia was present (Greenwood, et al., 2009).

The consensus in the literature is that inpatient hypoglycaemia is largely preventable. There is frequently a component within the delivery of care which, if modified in a timely manner, could prevent or reduce the risk of hypoglycaemia (Anthony, 2007; Huynh, Maynard, & Renvall, 2008; Smith, Winterstein, Johns, Rosenberg, & Sauer, 2005; Wagner, 2000).

The evidence that poor patient outcomes are associated with inpatient hypoglycaemia and that clinical staff fail to respond to or treat episodes effectively has prompted many institutions to develop guidelines for diabetes management and protocols specific to the treatment of hypoglycaemia (American College of Endocrinolgy & American Diabetes Association, 2006). Despite this, nursing care has continued to be suboptimal, particularly in regard to adherence to hospital protocols for the management of hypoglycaemia (Anthony, 2007). The observation that many patients in our Northland hospital were experiencing hypoglycaemia and that the hospital protocol for its management was not consistently followed was the catalyst for this study.

Study Design and Method

A retrospective audit of the treatment and progress notes of patients admitted to Whangarei Hospital between November 2009 and January 2010 was used to depict nursing adherence to the Northland District Health Board's (NDHB) protocol "Management of Hypoglycaemia in Patients with Diabetes". This secondary level facility is the region's main hospital, providing 223 inpatient beds and specialist care to the Northland population (Northland District Health Board, 2010). Ethical approval for this study was granted by the Northern X Regional Ethics Committee.

Whangarei Hospital has two general adult medical and two general adult surgical wards. All four wards were included to ensure that the sample was representative of the general adult inpatient population. Only patients with either Type One or Type Two Diabetes who had experienced an episode of inpatient hypoglycaemia, and who were prescribed an oral hypoglycaemic agent and/or insulin were included in the study. Patients were excluded if their diabetes was diet controlled, and those receiving Metformin as a monotherapy. Hypoglycaemia is not an identified side effect of this medication (Medsafe, 2006). Also excluded were patients who had been admitted with hypoglycaemia; those requiring a glucose insulin potassium infusion or receiving palliative care.

The study aimed to assess nursing management of 100 episodes of hypoglycaemia. Thirty seven cases met the study criteria. Treatment and progress notes were able to be accessed for 32 cases resulting in a total of 117 episodes of hypoglycaemia for audit. Oral therapy was used to treat 114 of these episodes. The sample was recruited retrospectively through a biweekly review of the wards' patient whiteboard or the shift handover sheets, which contained detailed information about diagnosis, past medical history and current management.

The most common primary diagnoses were associated with complications of peripheral vascular disease. Ten (32%) patients were admitted with either foot or lower limb complications such as ulcers or cellulitis, or required amputation or skin graft. Four patients had respiratory illnesses such as pneumonia; three were admitted with peritonitis; two with stroke and two with cardiac conditions. One of a further three patients had each undergone bowel urological or breast surgery. Other primary diagnoses included one episode each of diabetic ketoacidosis, acute renal failure, confusion, collapse, gastrointestinal bleed, and anaemia. Length of hospital admission ranged from 4 to 70 days, with an average of 14.75 days.

An audit tool was specifically developed and trialled for this study as no existing applicable tool could be sourced. This included consultation with a diabetes consultant and clinical nurse specialists, two of whom independently trialled the tool. Data gained during the trial were consistent and accurate. It was therefore deemed to have a degree of reliability and validity though not to the standard of a previously validated tool. Data collected included patient demographics such as age, gender, ethnicity (see Table 1) and information specific to hypoglycaemic events such as time, location, number, and duration of episodes.

To facilitate data collection and reduce the risk of transcription errors, data were entered directly into the audit tool in Microsoft Excel, where it was analysed. A range of descriptive statistics including nominal and ordinal measurements, frequency distribution, and measures of central tendency were used to summarise the findings in the form of tables and graphs.


The NDHB protocol identifies a capillary blood glucose level (CBG) <4.0mmol/l as the clinical indicator for the initiation of hypoglycaemia treatment. This is consistent with the standard adopted nationally in both community and inpatient contexts (Diabetes New Zealand, 2010). Capillary blood glucose levels ranged from 1.1-3.9 mmols/l at the time of detecting hypoglycaemia. Severe hypoglycaemia (CBG <2.2mmol/l) occurred in five (4.3%) cases. Of the initial CBG readings, 94 (80.3%) ranged between 3.0 and 3.9mmol/l.

The audit tool identified eight key steps in the protocol (Table 2). On detection of hypoglycaemia, the correct amount of glucose (step 1) was administered in 46 (40.4%) of the episodes in which oral treatment was provided (see Figure 1). LA Vitatabs were offered most frequently, with sugar dissolved in water also being offered. Three teaspoons of sugar, honey or jam was identified in the protocol as an alternative to Vitatabs. The predominant failure in step 1 was offering insufficient glucose and to supplement the initial glucose treatment with a complex carbohydrate, such as a meal, biscuits, or chocolate milk drink. The protocol specifically states that a complex carbohydrate should only be given once hypoglycaemia has been corrected. In 15 (13%) episodes, complex carbohydrate not glucose was the first treatment provided. In 5 (4.3%) episodes, no treatment at all was documented. A retest (step 2) of the CBG 10-15 minutes after giving glucose was achieved in 35 (30.7%) episodes. The median time for all retest times identified was 30 minutes. Time to retest ranged from 5 to 400 minutes, with one retest performed at 840 minutes.

Retreatment with glucose only (step 3) was correctly offered to 18 (25%) of the 72 patients who continued to experience hypoglycaemia after the initial glucose treatment. Complex carbohydrate was correctly withheld when hypoglycaemia persisted in 44 (38.6%) episodes (step 4). Once hypoglycaemia was corrected, a complex carbohydrate was provided in 44 (38.6%) of episodes (step 5).

The next scheduled dose of diabetic medication was given at the prescribed time in 81 (71.1%) episodes (step 6). Patients on oral hypoglycaemic agents were more likely to have their routine medication dose withheld post-hypoglycaemia than those receiving insulin. In 33 (28.9%) episodes, the prescribed diabetic medication was not given when scheduled.

Medical staff were informed (step 7) in 13 (11.4%) episodes where the patient was able to take oral treatment. Nurses' documentation (step 8) of the episode in the patients' treatment and progress notes gained the highest level of adherence of any step (102 episodes or 87.7%). Adherence to the protocol in this step was defined as either completing the NDHB diabetes record sheet, or an entry in the patient's treatment and progress notes recording the episode of hypoglycaemia. The purpose of this study was not to audit the quality of nursing documentation; therefore a formal audit was not undertaken. The quality of documentation ranged from the simple recording of the initial CBG reading on the diabetes record sheet, to a comprehensive description of the episode in the treatment and progress notes. Some nurses included a brief care plan, but there was no documentation to show that nurses had developed strategies to prevent recurrent episodes or had provided patient education.


The average time from detection to correction for all episodes was 85.5 minutes. Within 30 minutes of detection, 33 (36.7%) episodes were corrected. Within one hour 70 (59.8%) episodes had been corrected (see Figure 2). There was a high degree of recurrent hypoglycaemia, with 14 patients (43.8%) experiencing between two and four episodes and nine patients (28.1%) experiencing five or more episodes (see Figure 3).




The nursing management of hypoglycaemia documented in the treatment and progress notes demonstrated low adherence to the individual steps of the hypoglycaemia protocol. Protocols have been defined as "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances" (Anthony, 2008, p.314). They help to implement standards by including explicit statements regarding the standard of care to be provided (Bick, Fontenla, Rycroft-Malone, & Seers, 2008). An initial response to the detection of hypoglycaemia was identified in 105 (96%) of cases indicating that most nurses understood that treatment was required. However, there was a wide variation in the treatment provided suggesting that management was not consistently based on the protocol.

Nurses' failure to follow clinical protocols is not a new finding. One reason for this is that protocols are perceived as time-consuming for nurses to implement (Backhaus et al., 2010). This is illustrated in this audit by the low adherence to step 2 (35 episodes or 30.7%), which requires a retest 10 to 15 minutes after initial treatment.

Nurse to patient ratio continues to be one important determinant in regard to patient outcomes (Tourangeau et al., 2007). High workloads are the everyday reality in inpatient care. The nurse who is managing an already high workload may find providing one to one time specific care required by the protocol poses a significant challenge. Prioritization of nursing time may be influenced by the severity of the blood glucose result, with a lower result being allocated a higher priority. Conversely, the appearance and behaviour of the patient, especially during a mild or asymptomatic episode, may result in a failure to prioritise care.

In this study no attempt was made to determine reasons for not performing the retest as per the protocol. Failure to understand the potentially serious nature of untreated episodes may have been a factor. Hypoglycaemia is an adverse event. Severe hypoglycaemia is life threatening and is viewed as a sentinel event when occurring in hospital, because in most cases it is preventable (Quality Improvement Committee, 2009). Nurses may fail to understand this and, therefore, do not place a high priority on the management of hypoglycaemia. The presence of hypotension is likely to evoke a more immediate response. Some nurses perceive hypoglycaemia as being a frequent event in the life of the person with diabetes and therefore expect that full recovery without undue harm will routinely eventuate. The low cumulative adherence to the time specific steps of the protocol is indicative of poor understanding of the serious nature of hypoglycaemia, and can result in failure to prioritise care.

This is consistent with the findings of other studies (Anthony, 2007; Huynh, et al., 2008). Prolonged episodes (average time to correction was 85.5 minutes) were a feature of this study. All nurses receive education about the protocol during their orientation to the ward and through regular in-service sessions provided on the wards. However, the low overall adherence suggests that nurses were either not familiar with the protocol, could not adhere to it for some reason, or chose to disregard it. The findings of this study raise a question about nurses' understanding of the seriousness of hypoglycaemia and the importance of timely treatment.

The delivery of diabetes care in New Zealand is a cause for concern. Improving the knowledge and skills of all nurses providing care to people with diabetes is seen as an important strategy to improving outcomes for this patient group. This realisation prompted the development of the National Diabetes Nursing Knowledge and Skills Framework that includes the prevention, identification, and treatment of hypoglycaemia. These competencies have been aligned to the Nursing Council of New Zealand registration requirements (MidCentral District Health Board, 2009).

The finding that 23 out of 32 cases (71.9%) experienced recurrent episodes was concerning. Nurses need to be aware that during hospital admission patients with diabetes are at increased risk for developing hypoglycaemia. Risk factors relate to medical issues such as tight glycaemic control, a history of previous episodes, severe hepatic dysfunction, and impaired renal function. Other important risk factors include increasing age, inadequate capillary blood glucose monitoring, and reduced carbohydrate intake (Stanisstreet, Jones, Walden & Graveling, 2010). The presence of a prior hypoglycaemic event is considered to be a particularly important predictor for inpatient hypoglycaemia (Huynh et al., 2008). In this study, there was no evidence in the nursing documentation that an assessment of hypoglycaemic risk factors had been undertaken.

Another significant factor contributing to the high recurrence of hypoglycaemia found in this study was the failure to review glycaemic management after an episode. This finding is also consistent with other studies (Anthony, 2008; Huynh, et al., 2008; Smith et al., 2005). The protocol requires the causes of hypoglycaemia to be reviewed along with preceding diabetic medication doses. In this study the medication regimen was reviewed in only 20 episodes (17.5%). These reviews did not occur at the time of the episode but later at the request of nursing staff or as a result of a review by medical staff during routine ward rounds. A more timely review of the diabetes medications after the initial or a second episode may have reduced the rate of recurrent hypoglycaemia.

Strengths and Limitations

The researcher gathered all data thereby enhancing consistency in its collection. However, gaps in the quality and accuracy of the data collected are acknowledged. The failure to acquire precise data from the clinical record may have increased the potential for bias in the findings (Elliot, Haber, Lobiondo-Wood, Scheider, & Whitehead, 2007). CBG results are routinely recorded on the NDHB diabetes monitoring record which is held with the vital signs record on each patient's clipboard. The protocol also requires documentation in the patient's treatment and progress notes. The researcher identified that the standard of nursing documentation of episodes varied greatly and not all episodes were routinely recorded in the two required clinical records. This may have been a result of nurses failing to transfer vital patient information from their personal time management plan to official records rather than not adhering to steps of the protocol. The resulting incomplete official record of hypoglycaemia management is a confounding variable. The limitations associated with the use of a newly developed audit tool, compared to one with proven validity and reliability, are acknowledged.

Conclusions and Recommendations

Despite the provision of a hospital hypoglycaemia protocol to assist nurses to treat episodes according to best practice, management of hypoglycaemia was found to be suboptimal. Nurses did not consistently follow the recommended steps and in no single episode were all the steps achieved. There was little evidence to show that nurses used strategies to prevent hypoglycaemia and their sequelae. Nurses have a key role in the management of inpatient hypoglycaemia. Education for nurses concerning the detrimental effects of hypoglycaemia and the need to prioritise the care of the patient with hypoglycaemia is required. A review of the protocol in consultation with nurse educators and ward nurses may make the protocol a more nursing-centred document. Strategies to increase nurses' familiarity with, and access to, the protocol include pocket-sized laminated cue cards, posters, regular short in-service sessions, and hypoglycaemia management self-audit forms. Steps to prevent recurrent hypoglycaemia such as risk assessment, timely medication review and accurate nursing documentation should be developed. Future research should examine strategies to increase timely intervention with the correct treatment, such as the use of 'hypo-kits. The findings of this study indicate the need for further examination of the factors which contribute to non-adherence to the protocol. This may include factors such as knowledge of diabetes care, workload and time management and documentation. The hospitalised patient with diabetes is known to experience less favourable inpatient outcomes than the person who does not have diabetes. Episodes of inpatient hypoglycaemia further hinder the patient's return to wellbeing. It is incumbent on all nurses to provide evidence based and timely interventions for this common diabetes complication.


American College of Endocrinology & American Diabetes Association. (2006). Statement on in-patient diabetes and glycemic control. Diabetes Care, 29, 1955-1962. doi:10.2337/dc06-9913

American Diabetes Association. (2006). Standards of medical care in diabetes--2006. Diabetes Care, 29, S4-S42. http://care.

Anthony, M. (2007). Treatment of hypoglycemia in hospitalised adults: A descriptive study. The Diabetes Educator, 33(4), 709-715.

Anthony, M. (2008). Hypoglycemia in hospitalised adults. MedSurg Nursing, 17(1), 31-40.

Backhaus, B. R., Barnachea, D. F., Gardner, K. P., Hughes, S. K., Locke, C. L., & McEuen, J. A. (2010). An evidenced- based protocol for managing hypoglycemia. American Journal of Nursing, 110(7), 40-45. doi:10.1097/01.NAJ.0000383933.45591.1c.

Barnabas, K., Javed, S., Javed, Y., & Kaushal, K. (2010). A study of inpatient diabetes care on medical wards. Journal of Diabetes Nursing, 14(2), 56-62.

Berkley, J., & Lunt, H. (2006). Diabetes epidemiology in New Zealand--does the whole picture differ from the sum of its parts? The New Zealand Medical Journal, 119(1235).

Bick, D., Fontenla, M., Rycroft-Malone, J., & Seers, K. (2008). Protocol-based care: Impact on roles and service delivery. Journal of Evaluation in Clinical Practice, 14, 867-873. doi:10.1111/j.1365-2753.2008.01015.x.

Diabetes New Zealand. (2010). Low blood glucose (hypoglycaemia) for Type 2 diabetes. Retrieved from living_with_diabetes/type_2_diabetes/low_blood_glucose_hypo

Cagliero, E., Grant, R. W., Meigs, J. B., Nathan, D. M., & Wexler, D. J. (2007). Prevalence of hyper-and hypoglycemia among inpatients with diabetes. Diabetes Care, 30(2), 367-369.

Elliot, D., Haber, J., Lobiondo-Wood, G., Scheider, Z., & Whitehead, D. (2007). Nursing & midwifery research: Methods and appraisal for evidence-based practice (3rd ed.). Marrickville, NSW: Elsevier Australia.

Maynard, G. A., Huynh, P., & Renvall, M. (2008). Iatrogenic inpatient hypoglycemia: Risk factors, treatment, and prevention: analysis of current practice at an academic medical centre with implications for improvement efforts. Diabetes Spectrum, 21, 241-247. doi:10.2337/diaspect.21.4.241

Medsafe. (2006). Information for health professionals. Retrieved from

MidCentral District Health Board. (2009). National diabetes nursing knowledge and skills framework. Retrieved from http://www.

Ministry of Health. (2007). Diabetes surveillance: Population-based estimates and projections for New Zealand, 2001- 2011: Public Health Intelligence Occasional Bulletin NMiniso. 46 Retrieved from surveillance-population-based-estimates-and-projections-new-zealand-2001-2011

Ministry of Health. (2012b).Mortality and demographic data, 2009. Wellington, New Zealand: Author. Retrieved from http://www.

Ministry of Health. (2012a). The health of New Zealand adults 2011/12: Key findings of the New Zealand health survey. Wellington, New Zealand: Ministry of Health.

Moghissi, E. S., Korytkowski, M.T., DiNardo, M., Einhorn, D., Hellman, R., Hirsch, I. B., ... Umpierrez, G. E. (2009). American Association of Clinical Endocrinologists and American Diabetes Association concensus statement on inpatient glycemic control. Diabetes Care, 32(6), 1119-1131. doi:10.2337/dc09-9029

Northland District Health Board. (2006). Diabetes strategy He kaupapa oranga mo te mate huka i roto i Te Tai Tokerau. Retrieved from

Northland District Health Board. (2010). Northland District Health Board--Our hospitals. Retrieved from http://www.northlanddhb.

Quality Improvement Committee. (2009). Sentinel and serious events in New Zealand hospitals, 2007-2008. Wellington, New Zealand: Health Quality & Safety Commission. Retrieved from report-2007-08.pdf

Smith, W. D., Winterstein, A. G., Johns, T., Rosenberg, E., & Sauer, B. C. (2005). Causes of hyperglycemia and hypoglycemia in adult inpatients. American Journal of Health-Systems Pharmacy, 62, 714-719.

Stanisstreet, D., Walden, E., Jones, E., & Graveling, A. (2010). The hospital managment of hypoglycemia in adults with diabetes mellitus. London, United Kingdom: National Health Service. Retrieved from views/Care%20recs/Joint%20British%20Diabetes%20Societies%20Inpatient%20Care%20Group%20-%20The%20Hospital%20 Management%20of%20Hypoglycaemia%20in%20Adults%20with%20Diabetes%20Mellitus.pdf

Tourangeau, A. E., Doran, D. M., McGillis Hall, L., O'Brien Pallas, L., Pringles, D., Tu, J. V., & Cranley, L. A. (2007). Impact of hospital nursing care on 30-day mortality for acute medical patients. Journal of Advanced Nursing, 57(1), 32-44. doi:10.1111/j.1365-2648.2006.04084.x

Turchin, A., Matheny, M. E., Shubina, M., Scanlon, J. V., Greenwood, B., & Pendergrass, M. L., (2009). Hypoglycemia and clinical outcomes in patients with diabetes hospitalized in the general ward. Diabetes Care, 32, 1153-1157. doi:10.2337/ dc08-2127

Wagner, E. H. (2000). The role of patient care teams in chronic disease management. British Medical Journal, 320, 569- 572. doi:10.1136/ bmj.320.7234.569

Adrienne Coats, RN, MN, Clinical Nurse Specialist Diabetes, Northland District Health Board, Whangarei Hospital, NZ.

Dianne Marshall, RN, MA, Senior Lecturer, School of Nursing, University of Auckland, NZ.
Table 1
Characteristics of the Sample (n=32)

Characteristic                          Number   Percentage
                                         (n)        (%)
Age in years     Max                      85
                 Min                      48
                 Average                 66.3
                 Median                   68

Gender           Male                     13       40.6%
                 Female                   19       59.4%

Ethnicity        Maori                    17       53.1%
                 NZ European              13       40.6%
                 Pacific Island           1         3.1%
                 Other                    1         3.1%

Patient          Surgical                 12       37.5%
numbers by       Medical                  20       62.5%

Diabetes         Type 1                   3         9.4%
                 Type 2                   29       90.6%

Therapy          Oral Hypoglycaemic       9        28.1%
                   Agents only (OHAs)
                 Insulin Therapy only     18       56.2%
                 Combination Therapy      5        15.7%
                   (Insulin + OHAs)

Table 2
Key Steps in the Protocol (Oral Therapy)

Step                       Action

1       Gives 3 to 5 vita tabs or 9-15gm glucose
2       Retests CBG 10-15 minutes
3       Retreats with glucose only if CBG < 4mmol/l
4       Withholds complex CHO until CBG > 4mmol/l
5       Gives CHO snack/meal when CBG > 4mmol/l
6       Gives usual diabetic medications at
          prescribed times when CBG > 4mmol/l
7       Informs medical staff of hypoglycaemia
8       Documents interventions in treatment and
          progress notes
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Author:Coats, Adrienne; Marshall, Dianne
Publication:Nursing Praxis in New Zealand
Article Type:Report
Geographic Code:8NEWZ
Date:Jul 1, 2013
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