Nurses’ knowledge of
inpatient hypoglycaemia
management
Eswari Chinnasamy, Ananya Mandal,
Sanna Khan, Farhana Iqbal, Natasha Patel
Inpatients with diabetes frequently experience episodes of
hypoglycaemia, which are often managed by nurses. The present
authors audited their local practice and found several deicits with
regard to inpatient hypoglycaemia management. Following this,
nurses were trained on the hypoglycaemia management guideline
and hypo-boxes were introduced. Subsequent re-audits identiied
some recurring deicits. Using a questionnaire survey, this study
aimed to identify if gaps in nurses’ knowledge explain the recurring
deicits in the hypoglycaemia management audits. Of 100 nurses
who participated in the study, only 51% had formal training in
hypoglycaemia management, and only 28% nurses knew the
common symptoms of hypoglycaemia listed in the questionnaire.
Interestingly, 73% of the hypoglycaemic episodes were detected by
routine checks and this was predicted by nurses in the survey. The
authors conclude that there is a lack of knowledge among ward
nurses regarding hypoglycaemia management and that further
training is necessary.
H
ypoglycaemia is a major barrier
to intensive glycaemic control,
and occurs in 7.7% of all diabetes
hospital admissions, leading to increased
length of hospital stay, cost and mortality rates
(Curkendall et al, 2009; Turchin et al, 2009).
The majority of hypoglycaemic episodes are
managed by nurses and guidance for this is
provided in the The Hospital Management of
Hypoglycaemia in Adults with Diabetes Mellitus
(Stanisstreet et al, 2010) document.
The present authors have addressed nurses’
management of inpatient hypoglycaemia
following an audit of their local practice.
Journal of Diabetes Nursing Vol 15 No 8 2011
Hypo-boxes were introduced as well as
hypoglycaemia management guidelines and
staff training to standardise hypoglycaemia
management. Subsequent re-audits identiied
some recurring deicits, such as not treating
blood glucose levels of 3–4 mmol/L, not using
the correct carbohydrates to treat hypoglycaemia,
not rechecking blood glucose levels after
15 minutes and not performing laboratory
glucose checks during hypoglycaemic episodes.
In this article, the authors present the
indings of a study to determine if gaps in
nurses’ knowledge explain the recurring deicits
in the hypoglycaemia management re-audits.
Article points
1. The objective of this
study was to determine
if gaps in nurses’
knowledge explain
the recurring deicits
in the hypoglycaemia
management re-audits.
2. A total of 100 responses
to the questionnaire on
inpatient hypoglycaemic
management were received
from participants (80%
staff nurses and 20%
senior or charge nurses).
3. Only 51% of the
participating nurses
were formally trained to
manage hypoglycaemia
and 28% of nurses
recognised all symptoms
of hypoglycaemia.
4. The results of this survey
have shown that there is
a lack of knowledge of
inpatient hypoglycaemia
management among
nurses, thus providing
explanations for recurrent
deicits in re-audits.
Key words
- Hypoglycaemia
- Inpatient care
- Nurse knowledge
Authors’ details can be found
at the end of this article.
313
Nurses’ knowledge of inpatient hypoglycaemia management
Methodology
Results
The authors developed a questionnaire
(Box 1) based on their hospital hypoglycaemia
management guidelines. Nurses on the adult
wards were asked to participate over a 1-week
period. This study was conducted in a tertiary
hospital in London.
A total of 100 responses were received from
participants (80% staff nurses and 20% senior
or charge nurses). All the participating nurses
came across patients with diabetes in their
wards. At present, all patients with diabetes
undergo regular capillary blood glucose (CBG)
Box 1. Questionnaire for nursing staff on inpatient hypoglycaemic (low blood glucose) management.
Please circle the appropriate answer
1.
Grade:
Staff nurse
Senior nurse
Nurse in charge
2. Base ward:
3. Do you come across diabetic patients in your ward?
Yes / No
4. Are you aware of the existence of the Inpatient Hypoglycaemia Guideline in the Trust?
Yes / No
5. Have you had training on hypoglycaemia management?
Yes / No
6. What is the cut-off capillary blood glucose level (mmol/L) for hypoglycaemia as per local protocol?
<2.5
<3
<4
<5
7. Please select the symptom(s) of hypoglycaemia from the following:
Hunger
Shaking
Sweating
Confusion
Headache
Fits
8. Which antidiabetes medication(s) commonly causes hypoglycaemia?
Metformin
Glitazone
Gliclazide
Insulin
9. What would you use to treat the hypoglycaemia? Please give examples and quantities.
10. Please list the contents of the hypo-box.
11. Insulin needs to be omitted after treatment of a hypoglycaemic episode.
True / False / Not sure
12. Is it essential to recheck the blood glucose?
Yes / No / Not sure
13.
14.
15.
16.
17.
18.
314
If yes, when do you need to check?
If no, why?
Is it important to take a venous blood sample for lab glucose?
Yes / No / Not sure
Do you take venous blood glucose in hypoglycaemia in your practice?
Yes / No
Do you document the hypoglycaemia episode in medical notes for doctors to review?
Yes / No
Do you routinely check capillary blood glucose for all diabetics?
Yes / No
How do you think most hypoglycaemias in the hospital are detected?
Routine check
Suspected by patients
Suspected by staff
Do you think hypoglycaemia increases mortality (death)?
Yes / No / Not sure
Journal of Diabetes Nursing Vol 15 No 8 2011
Nurses’ knowledge of inpatient hypoglycaemia management
monitoring (at 0600, 1200, 1800 and 2200 hours and, additionally,
at 0200 hours as needed). The mean age of patients in previous
audits was 70 years. Of these, 93% of unique hypoglycaemic
episodes occurred in people with type 2 diabetes. Recurrent
hypoglycaemic episodes were common among older people with
severe renal impairment on sulphonylureas, and in people taking
insulin, those with cognitive dysfunction and those with poor oral
intake. A great proportion (47% [64/137]) of the hypoglycaemic
episodes in the audits occurred between 2200 and 0600 hours.
The responses to the questionnaire (Box 1) showed that only
51% of the participating nurses were formally trained to manage
hypoglycaemia and 77% were aware of the new hospital guideline.
Only 58% considered a blood glucose level of <4 mmol/L to be
hypoglycaemia (Figure 1); this may explain why some patients
in the previous audits with CBG levels of 3–4 mmol/L were
not treated. Only 28% of nurses recognised all symptoms of
hypoglycaemia and 29% recognised just three or less symptoms.
This is an important inding as many people with hypoglycaemia
might go unnoticed with potentially serious consequences.
In terms of the treatment of hypoglycaemia, 73% responded
that they would use some form of rapid-acting carbohydrate, but
only 10% said they would treat with quick-acting carbohydrates
followed by slowly digested carbohydrates. Only 33% would
recheck CBG within 15 minutes, while 28% were not sure when to
recheck CBG and others were variable from 30 minutes to 1 hour.
At least 57% did not feel the need for measurement of venous blood
glucose levels during a hypoglycaemic episode and in the previous
hypoglycaemia management audits this measurement was not
performed in any patient.
More positively, the majority (73% [100/137]) of hypoglycaemic
episodes in inpatients were successfully detected during routine
testing, and in the survey 75% of participating nurses felt they were
detecting hypoglycaemic episodes by routine checking. This was an
unexpected inding both in the previous hypoglycaemia management
audits and the survey. This highlights the problem of hypoglycaemia
unawareness in inpatients with diabetes.
People on insulin are at a high risk of hypoglycaemia (UK
Prospective Diabetes Study Group, 1998). Omission of insulin
after managing a hypoglycaemic episode is a common problem
and this was highlighted in the present study as 66% of the nurses
felt that they would and should omit insulin after treatment of a
hypoglycaemic episode (Figure 2). Of the surveyed nurses, 76% felt
that hypoglycaemia increases mortality rates.
Discussion
This study was undertaken with the intention of it being a training
module rather than research. Participants of this study took it as
a learning experience and this prompted a rapid adaptation of the
hypoglycaemia management guideline.
Journal of Diabetes Nursing Vol 15 No 8 2011
315
Nurses’ knowledge of inpatient hypoglycaemia management
Figure 1. Responses to the question: What is the cut-off capillary blood
glucose level (mmol/L) for hypoglycaemia as per local protocol?
70
Responses (%)
60
50
40
30
20
10
<2.5
<3
<4
<5
Not
documented
Capillary blood glucose level (mmol/L)
Figure 2. Responses to the statement: Insulin needs to be omitted after
treatment of a hypoglycaemic episode.
70
Responses (%)
60
50
40
30
20
10
True
False
Not sure
In diabetes care, the prevention of
microvascular complications is the main
beneit of intensive blood glucose management,
but the downside is the increased frequency
of severe hypoglycaemic episodes (NICE–
SUGAR Study Investigators et al, 2009). There
have been reports of increased mortality rates
in people receiving critical care associated with
tight glycaemic control, particularly owing to
hypoglycaemia. When severe hypoglycaemic
episodes occur, the individual needs assistance
from others for treatment, regardless of the
blood glucose value. A recent meta-analysis
316
of large cardiovascular (CV) outcome studies
in diabetes including ACCORD (Action to
Control CV Risk in Diabetes), ADVANCE
(Action in Diabetes and Vascular Disease)
and VADT (Veterans Affairs Diabetes Trial)
suggests that there is a direct correlation
between the incidence of severe hypoglycaemia
and CV mortality (Mannucci et al, 2009). It is
therefore essential, particularly in older people
with long durations of diabetes and CV disease
(CVD), to avoid severe hypoglycaemia and
choose therapy with the least risk of causing
hypoglycaemia.
Studies have shown that the prevalence of
inpatient diabetes is 10–25% (Sampson et al,
2007). In a study by Turchin et al (2009), the
incidence of hypoglycaemic episodes was
7.7% in inpatients with diabetes and this is
associated with increased length of stay, cost
and mortality (Curkendall et al, 2009). In
these studies, the blood glucose cut-off level for
hypoglycaemia was 50 mg/dL (2.8 mmol/L).
However, the present authors’ local policy is
to treat blood glucose levels of <4 mmol/L as
hypoglycaemia. A study by Bailon et al (2009)
showed a signiicantly higher incidence of
hypoglycaemia during nighttime compared
with that experienced during the day. The
audits carried out by the present authors
showed similar results. As these audits were
performed by reviewing patient notes and
charts it is dificult to explain the high
incidence of nocturnal hypoglycaemia, but it
may be related to inappropriate timing or size
of meals in relation to diabetes medications.
There are multiple potential causes
for inpatient hypoglycaemia including
(Stanisstreet et al, 2010):
l Inappropriately timed diabetes medications
for meal.
l Incorrect insulin prescribed or administered.
l Recovery from acute illness or stress.
l Intravenous insulin infusion with or without
glucose infusion.
l Missed or delayed meals.
l Smaller levels of carbohydrates than usual.
l Change of the timing of the biggest meal of
the day.
l Lack of access to snacks in between meals.
Journal of Diabetes Nursing Vol 15 No 8 2011
Nurses’ knowledge of inpatient hypoglycaemia management
l Prolonged
duration of “nil by mouth”.
l Reduced appetite.
Individuals aged >65 years, who represent
the majority of people with type 2 diabetes,
are at high risk of experiencing severe
hypoglycaemia (Zammitt and Frier, 2005;
Amiel et al, 2008). Bremer et al (2009) showed
that subjective hypoglycaemia unawareness
is a signiicant problem in people aged
>65 years compared with those aged <65 years
despite having no difference in the counterregulatory hormonal response. The majority
of the patients from the present authors’ audits
were also aged >65 years and had multiple
comorbidities including diabetic complications
and CVD. Hypoglycaemia unawareness also
increases the risk of severe hypoglycaemia
by up to three-fold (Meneilly et al, 1994;
Spyer et al, 2000). The adrenergic response
to hypoglycaemia is gradually attenuated by
antecedent hypoglycaemia as the threshold
for activation shifts to lower plasma glucose
concentrations (Cryer, 2004), which results in
hypoglycaemia unawareness.
The present authors found that most
hypoglycaemic events were detected during
routine testing. This may have resulted from
reduced hypoglycaemia awareness, cognitive
impairment or a reduced level of consciousness
owing to acute illness. Although omitting insulin
therapy following the management of an episode
of a hypoglycaemic episode is strongly advised
against, 66% of the nurses who responded to the
survey felt that they should omit insulin therapy.
Getting this message across is one of the main
priorities for future training sessions.
Future plans
As hypoglycaemia is a signiicant problem for
inpatients with diabetes with its associated
morbidity, mortality and high cost, good
understanding of the impact of hypoglycaemia
and knowledge of management are essential
for nurses to treat these episodes effectively.
Recognition of hypoglycaemic symptoms
by staff is important to treat these events
appropriately. Addressing these deiciencies by
providing compulsory training for all nursing
staff is now being planned.
Journal of Diabetes Nursing Vol 15 No 8 2011
Diabetes link nurses have been identiied
in each clinical area and they will ensure that
their staff are trained and supported. They
will also be the irst port of call for other ward
nurses. The present authors plan to repeat
the survey after this compulsory training.
Institutional blood glucose monitoring is
an emerging technology for monitoring
blood glucose levels in hospitalised patients;
consideration is being given to introducing
this system. This has been associated with
improved glucose control (Boaz et al, 2009)
and will also make future audits much easier.
A similar lack of knowledge among medical
and nursing house staff has been demonstrated
in a study by Trepp et al (2010). This study
focused on questions related to inpatient
management of diabetes such as antidiabetes
therapy, hypoglycaemia, ketoacidosis and
blood glucose targets. In the study by Trepp
et al, participants scored high on questions on
hypoglycaemia (59±25%) and low on questions
on oral antidiabetes therapy (32±32%) and
ketoacidosis (32±22%). In the future, assessing
these different areas of knowledge would be
helpful to tailor training needs.
Conclusion
The results of this survey show that there is a
lack of knowledge of inpatient hypoglycaemia
management among nurses, thus providing
potential explanations for recurrent deicits in
re-audits. The surprising result in this survey
was the detection of a signiicant proportion
of hypoglycaemic episodes by routine testing.
The authors believe that by providing
compulsory training for nurses, standardised
management of hypoglycaemia for inpatients
with diabetes can be achieved.
n
Authors
Eswari Chinnasamy, Clinical Teaching Fellow
in Diabetes and Endocrinology; Sanna Khan,
Medical Student; Farhana Iqbal, Foundation Year
Doctor; Natasha H Patel, Consultant Physician
and Diabetologist, Department of Diabetes and
Endocrinology, St George’s Hospital, London.
Ananya Mandal, Assistant Professor in Pharmacology,
Nil Ratan Sircar Medical College & Hospital,
Kolkata, West Bengal, India.
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