Identifying risk factors for severe hypoglycemia in hospitalized patients with diabetes.

OBJECTIVE: Some of the deleterious effects of hypoglycemia in hospitalized patients include increased rates of mortality and longer length of stay. Our primary objective was to identify the risk factors associated with severe hypoglycemia to identify those patients at highest risk. METHODS: The medical records of 5,026 patients with diabetes mellitus (DM) admitted in 2010 were reviewed to identify those patients that developed severe hypoglycemia (blood glucose [BG] <40 mg/dL). We performed χ2 tests to assess statistical significance. Adjusted logical regression was used to determine the risk factors for hypoglycemia in the hospital. RESULTS: Out of 5,026 DM patients included in our review, 81 experienced severe hypoglycemia (1.6%). Statistically higher proportions of chronic kidney disease (CKD; 69.1% vs. 46.9%, P<.001), congestive heart failure (CHF; 48.1% vs. 28.5%, P<.001), sepsis (49.4% vs. 12.5%, P<.001), insulin use (45.7% vs. 26.04%, P = .000), type 1 DM (21% vs. 5.1%, P = .000), and cirrhosis (14.8% vs. 7.2%, P = .009) were seen in the severe hypoglycemic group compared to the nonsevere hypoglycemic group. Overall, 84% of patients who experienced an episode of severe hypoglycemia in the hospital (BG <40 mg/dL) had a previous episode of hypoglycemia (BG <70 mg/dL). The odds ratios (ORs) for type 1 DM, sepsis, previous hypoglycemia, and insulin use were 3.43 (95% confidence interval [CI] 1.81, 6.49), 2.64 (95% CI 1.6, 4.35), 46.1 (95% CI 24.76, 85.74), and 1.66 (95% CI 1.02, 2.69), respectively. CONCLUSION: Prior episodes of hypoglycemia in the hospital, the presence of type 1 DM, insulin use, and sepsis were identified as independent risk factors for the development of severe hypoglycemia in the hospital.

Fragmented QRS complexes-a novel but underutilized electrocardiograhic marker of heart disease.

The electrocardiogram is the mainstay approach for diagnosing a myocardial infarction (MI). The diagnosis of an old MI and the identification of myocardial scar via the electrocardiogram are difficult because there are no other specific signs for a non-Q-wave MI. In this article, we will review the fragmented QRS and its role in identifying myocardial scar and depolarization abnormalities in patients with coronary artery disease.

Insulin administration and meal delivery coordination for hospitalized patients.

BACKGROUND: Through efforts to continuously improve the quality of care provided to hospitalized patients with diabetes by evaluation of adherence to standards and performance metrics, we identified an opportunity for improvement. METHODS: A plan-do-study-act cycle was initiated with the goal of enhancing patient satisfaction with the timing of blood glucose monitoring, insulin administration, and meal delivery in the hospital. RESULTS: Despite an educational intervention with the nursing staff, patient satisfaction with mealtime insulin administration decreased from 83% to 78%. CONCLUSION: Education of frontline staff was not adequate to achieve our quality improvement goal.

An inpatient hypoglycemia committee: development, successful implementation, and impact on patient safety.

BACKGROUND: Hypoglycemia is a major and preventable cause of morbidity and mortality in the hospital setting. Prevention of hypoglycemia in hospitalized patients relates to the practice climates and prescribing patterns of physicians, the development of safe and effective protocols, and the education of providers and nursing staff on hypoglycemia and its consequences. METHODS: Many hospitals use multidisciplinary committees to address issues of healthcare quality and patient safety. This article describes the creation of a subspecialty Hypoglycemia Committee, its design and function, and the steps taken to reduce hypoglycemia in a large, tertiary acute care hospital. RESULTS: The committee's initiatives included a systematic investigation of all severe hypoglycemic events, the development of a standalone hypoglycemia treatment protocol, reduction of sliding scale insulin therapy, revision of insulin order sets, and education of physicians and house staff. Hypoglycemic events have consequently decreased. CONCLUSION: The Hypoglycemia Committee is unique in that every case of severe hypoglycemia is reviewed by physicians, endocrinologists, and diabetes specialists. This multidisciplinary approach can effect measurable decreases in preventable hypoglycemic events.