Download Hypoglycaemia mgt of the adult inpatient with diabetes

Hypoglycaemia Management of the Adult Inpatient with Diabetes
Version
2
Name of responsible (ratifying) committee
Formulary and Medicines Committee
Nursing Midwifery Advisory Committee
Resuscitation Team
Date ratified
19th September 2014
Document Manager (job title)
Diabetes Specialist Nurse
Date issued
13th October 2014
Review date
12th October 2016
Electronic location
Clinical Guidelines
Related Procedural Documents
Key Words (to aid with searching)
Hypoglycaemia, Diabetes
Version Tracking
Version
Date Ratified
Brief Summary of Changes
2
Sept 2014
Change from using glucose 50% to glucose 20%
Hypoglycaemia Management of the Adult Inpatient with Diabetes Issue 2 13/10/2014
Review date 12/10/2016
Page 1 of 15
Author
CONTENTS
QUICK REFERENCE GUIDE....................................................................................................... 3
1. INTRODUCTION.......................................................................................................................... 4
2. PURPOSE ................................................................................................................................... 4
3. SCOPE ........................................................................................................................................ 4
4. DEFINITIONS .............................................................................................................................. 4
5. DUTIES AND RESPONSIBILITIES .............................................................................................. 6
6. PROCESS ................................................................................................................................... 7
7. TRAINING REQUIREMENTS ...................................................................................................... 8
8. REFERENCES AND ASSOCIATED DOCUMENTATION ............................................................ 8
9. EQUALITY IMPACT STATEMENT .............................................................................................. 8
10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS ........................................ 10
Hypoglycaemia Management of the Adult Inpatient with Diabetes Issue 2 13/10/2014
Review date 12/10/2016
Page 2 of 15
QUICK REFERENCE GUIDE
This policy must be followed in full when developing or reviewing and amending Trust procedural
documents.
For quick reference the guide below is a summary of actions required. This does not negate the need
for the document author and others involved in the process to be aware of and follow the detail of this
policy.
To minimise risk of hypoglycaemia:
On recognition of a hypo:
Patients should be assessed on admission as to:
 Their usual hypo signs
 How often and when they suffer from hypos
 Their usual treatment of hypos

Ensure that the patient:
 knows the routine of the ward regarding meals and snacks
 Has a supply of snacks close to hand
 Receives their diabetic medication at the appropriate times in relation to meals
MILD
Alert, conscious and able to swallow
MODERATE
Drowsy, uncooperative and/or
risk of choking
Test capillary glucose if
possible and initiate treatment
immediately using HYPOBOX
Hypoglycaemia Kit to prevent
further harm to the patient. If
patient is asymptomatic
repeat test.
SEVERE
Call 2222 and Fast Blp Doctor
Unconscious and potential for no gag
reflex, and/or fitting, and/or NBM
STEP ONE
 Initially administer 1x25g Glucose 40%
oral gel from the hypoglycaemia kit
allowing it to be swallowed
STEP TWO
 Repeat at 5-15 min intervals as necessary
depending on patient symptoms and
glucose concentrations.
 If Glucogel unavailable use 10-20g fast
acting glucose such as 2 tsp sugar in
water or 200ml glass of fizzy drink or
patients own remedy if appropriate
 If patient deteriorates move to yellow or
red guidance
1.
STEP THREE
To prevent glucose levels falling again
ensure long-acting carbohydrates such as
adequate amounts of bread/potato/rice is
eaten with a meal or a snack such as 2-3
biscuits, fruit, current bun is eaten if it is not a
meal time. Continue regular monitoring for 24
– 48 hours and reflect on cause of hypo
event
STEP ONE
STEP ONE
 Initially administer ONE or TWO
tube(s) 25g Glucose 40% oral gel
from the hypoglycaemia kit, inside
the cheek. Massage outside of
cheek allowing it to be
absorbed.
 Check ABC
 Place in recovery if required
 Administer intramuscular injection
(lateral arm or thigh) of Glucagon using
GlucaGen HypoKit 1mg stored in
locked ward fridge
 Do not leave patient
STEP TWO
 Repeat using one tube at 5-15 min
intervals as necessary depending
on patient symptoms and glucose
concentrations.
 If patient deteriorates move to
red guidance
STEP THREE
Follow as per green step three
 NB: Glucagon has little effect in
chronically malnourished / alcoholics
/ prolonged starvation / severe liver
disease / renal failure
 If no reponse from Glucagon within 5-10
minutes, doctor to administer IV
injection of 50mls of 20% glucose,
administered slowly through a large
vein and large gauge cannula. The
remaining 50mls may be given after
10mins if blood glucose less than
4mmol/L.
STEP TWO
 Once conscious, follow yellow step one
and two
STEP THREE
Follow as per green step three
INSULIN SHOULD NOT BE OMITTED FOLLOWING AN EPISODE OF HYPOGLYCAEMIA.
If you are concerned, patients should be assessed for a smaller insulin dose rather than an omission.
BGLs will be erratic following a hypoglycaemic event and patients can feel quite unwell for up to 48 hours.
Refer to Diabetes Specialist Team if concerned
Hypoglycaemia Management of the Adult Inpatient with Diabetes Issue 2 13/10/2014
Review date 12/10/2016
Page 3 of 15
INTRODUCTION
All people with diabetes who are administering oral anti-diabetic medications or insulin therapy
have the potential to suffer from hypoglycaemic events. When combined with altered routines
while an inpatient, this risk increases. Hypoglycaemic events are usually easily treated if
appropriate measures are taken. If incorrect treatment is provided, or treatment is delayed,
serious harm can ensue.
2. PURPOSE
This guideline has been developed to assist staff in the appropriate management decisions
regarding treating a person having a hypoglycaemic event. Staff will understand how to
recognise a hypoglycaemic event, what the appropriate treatment options are, and subsequent
monitoring of recovery to ensure patient safety and comfort.
Staff will also be able to acknowledge groups of patients who standard hypoglycaemia
treatment may be less effective.
This guideline will assist PHT registered and unregistered nurses and medical staff.
3. SCOPE
This guideline will apply to adult inpatients who have Type 1 or Type 2 diabetes requiring
treatment secondary to a confirmed hypoglycaemic event; capillary blood glucose reading of
approximately 4mmols/l or less, or as a result of professional judgment prior to testing and
confirming blood glucose level (1)
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises
that it may not be possible to adhere to all aspects of this document. In such circumstances,
staff should take advice from their manager and all possible action must be taken to
maintain ongoing patient and staff safety’
4. DEFINITIONS
Diabetes


Type 1 diabetes is an autoimmune disease characterised by hyperglycaemia resulting from
absolute deficiency of insulin affecting a heterogeneous group of people
Type 2 diabetes is a metabolic disease characterised by hyperglycaemia resulting from
relative insulin deficiency and insulin resistance affecting a heterogeneous group of people (2).
Hypoglycaemia

Hypoglycaemia results from an imbalance between glucose supply, glucose utilization, and
insulin levels resulting in more insulin than is needed at that time (3)
Hypoglycaemia is defined as a blood glucose level being equal or less than 4mmols/l, with
or without symptoms (1). Hypoglycaemia can occur not only with people who are requiring
insulin treatment, but also those who are taking oral anti-diabetic tablets such as gliclazide or
Pioglitazone (1). Insulin and Sulphonylureas (such as gliclazide) tablets give most risk of
hypoglycaemic events. Hypoglycaemic events are common but should not be a daily
normality. Hypoglycaemia is a side effect of treatment for diabetes and therefore is unlikely
to occur in people treated with diet and exercise alone.
Patient perception of hypoglycaemia

For the person with diabetes, the fear of having a hypo can outweigh the concern about the
Hypoglycaemia Management of the Adult Inpatient with Diabetes Issue 2 13/10/2014
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Page 4 of 15
future development of complications (4). Patient perception of hypoglycaemia may vary so it is
useful to record a blood glucose level prior to giving any treatment to confirm what the patient
is feeling is actually a hypoglycaemic event. Hypoglycaemia warning signs may be distorted
if a person has had elevated blood glucose levels over some time. These people may
experience hypoglycaemia symptoms above 4mmols/l and thus generally should not be
treated at this stage (2). However, eating a small amount of complex carbohydrates will help
to alleviate the hypoglycaemic symptoms without elevating the glucose level uncontrollably.
Hypoglycaemia warning signs

Hypoglycaemia symptoms and the level at which they start, vary from person to person.
Identifying symptoms most commonly include:
Shaking/ tremor/tingling
Faintness/weak
Feeling of hunger
Anxiety
Irritability/aggression
Sweating
Poor concentration/confusion/forgetful
Headache
Abnormal behaviour
Palpitations/tachycardia
(5)
Loss of hypoglycaemia warning signs

Loss of warning signs of hypoglycaemia is common among insulin-treated patients and can
be a serious hazard. Very tight control of diabetes lowers the blood glucose concentration
needed to trigger hypoglycaemia symptoms and an increase in the frequency of
hypoglycaemic episodes reduces the warning symptoms experienced by the patient. Betablockers can also blunt hypoglycaemia awareness and delay recovery. It has been reported
that conversion to human insulin from animal insulin also contributes to loss of warning signs
(2)
. However, it must be highlighted to the patient that any change in insulin product may give
rise to altered hypoglycaemic awareness, signs and symptoms; hence the need for the
person with diabetes to monitor their blood glucose levels closely in these circumstances.
Common causes of hypoglycaemia

Identifying precipitating factors that may lead to a hypoglycaemic event may help to prevent
or limit occurrence. Precipitating factors include:
Inadequate carbohydrate or delayed meal
Oral anti-diabetic agents especially
Sulphonylureas administered in the elderly
Stress and/or hot weather
Potentiating drugs such as warfarin or
fibrates
Too much insulin
Excessive or unusual amounts of exercise or
activity
Hepatic and/or renal disease
Change of daily routine
(5)
Delayed treatment for hypoglycaemia
It is essential that all hypoglycaemic episodes are treated immediately. An omission of
treatment or delay in treatment can at the very least result in elevated glucose levels due to
metabolic changes which are known as re-bound hyperglycaemia, some hours after the event.
However, omission of treatment and delays can also lead to confusion, coma, convulsions,
brain damage, reduced consciousness, and in severe cases death (5)
Glucagon
Glucagon is a hyperglycaemic agent that mobilises hepatic glycogen, which is released into the
blood as glucose.
Hypoglycaemia Management of the Adult Inpatient with Diabetes Issue 2 13/10/2014
Review date 12/10/2016
Page 5 of 15
Groups of patients which hypo treatment and glucagon may be less effective

Renal impairment / failure: People with renal impairment or failure are more at risk of
unpredictable and prolonged hypoglycaemia as insulin can not be cleared as effectively from
the body.
In the presence of renal impairment or failure, glycogen stores may be lower than usual and
renal glycogen stores absent, thus glucagon therapy may have reduced effect in raising
glucose levels.

Liver impairment / alcoholics / prolonged starvation / malnourished: People who have liver
impairment or failure will be more at risk of unpredictable or prolonged hypoglycaemia as they
are unable to store sufficient amounts of glycogen.
Glucagon will not be effective in patients whose liver glycogen is depleted. For that reason,
glucagon has little or no effect when the patient has been fasting for a prolonged period, is
malnourished, has liver impairment or failure, alcoholics or alcohol induced hypoglycaemia
In the above cases consideration should be given to earlier use of intravenous glucose,
especially if inadequate response to an initial glucagon injection is noted.
5. DUTIES AND RESPONSIBILITIES
Registered Nurse / Midwife – Act promptly by initiating appropriate treatment as outlined in
this guideline with regular follow up monitoring of glucose levels and examination of possible
causes to prevent further occurrences.
Doctors – All patients should be assessed for the need to prescribe GlucaGen HypoKit 1mg in
addition to usual hypoglycaemia treatment options, but particular consideration should be given
to those patients experiencing sudden severe hypoglycaemic episodes, or those who do not
experience hypoglycaemia warning signs.
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Review date 12/10/2016
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6. PROCESS
To minimise risk of hypoglycaemia:
Patients should be assessed on admission as to:
 Their usual hypo signs
 How often and when they suffer from hypos
 Their usual treatment of hypos
Ensure that the patient:
 knows the routine of the ward regarding meals and snacks
 Has a supply of snacks close to hand
 Receives their diabetic medication at the appropriate times in relation to meals
On recognition of a hypo:

Test capillary glucose if possible and initiate treatment immediately using HYPOBOX Hypoglycaemia Kit to prevent
further harm to the patient. If patient is asymptomatic repeat test.
MILD
Alert, conscious and able to
swallow
MODERATE
Drowsy, uncooperative and/or
risk of choking
STEP ONE
STEP ONE
STEP ONE
 Initially administer ONE tube x 25g
Glucose 40% oral gel from the
hypoglycaemia kit allowing it to
be swallowed
 Initially administer ONE or TWO
tube(s) of 25g Glucose 40% oral
gel from the hypoglycaemia kit,
inside the cheek. Massage
outside of cheek allowing it to
be absorbed.
 Check ABC
 Place in recovery if required
 Administer intramuscular injection
(lateral arm or thigh) of Glucagon
using GlucaGen HypoKit 1mg
stored in locked ward fridge
 Do not leave patient
STEP TWO
 Repeat at 5-15 min intervals as
necessary depending on patient
symptoms and glucose
concentrations.
 If Glucogel unavailable use 10-20g
fast acting glucose such as 2 tsp
sugar in water or 200ml glass of
fizzy drink or patients own remedy
if appropriate
STEP TWO
 Repeat using one tube at 5-15 min
intervals as necessary depending
on patient symptoms and glucose
concentrations.
 If patient deteriorates move to
red guidance
 If patient deteriorates move to
yellow or red guidance
STEP THREE
To prevent glucose levels falling
again ensure long-acting
carbohydrates such as adequate
amounts of bread/potato/rice is eaten
with a meal or a snack such as 2-3
biscuits, fruit, current bun is eaten if it
is not a meal time. Continue regular
monitoring for 24 – 48 hours and
reflect on cause of hypo event
STEP THREE
Follow as per green step three
SEVERE
Call 2222 and Fast Blp Doctor
Unconscious and potential for no
gag reflex, and/or fitting, and/or NBM
 NB: Glucagon has little effect in
chronically malnourished /
alcoholics / prolonged starvation
/ severe liver disease / renal
failure
 If no reponse from Glucagon within
5-10 minutes, doctor to administer
IV injection of 50mls of 20%
glucose, administered slowly
through a large vein and large
gauge cannula. The remaining
50mls may be given after 10mins if
blood glucose less than 4mmol/L.
STEP TWO
 Once conscious, follow yellow step
one and two
STEP THREE
Follow as per green step three
INSULIN SHOULD NOT BE OMITTED FOLLOWING AN EPISODE OF HYPOGLYCAEMIA.
If you are concerned, patients should be assessed for a smaller insulin dose rather than an omission.
Hypoglycaemia
Management of the Adult Inpatient with Diabetes Issue 2 13/10/2014
BGLs will be erratic following a hypoglycaemic event and patients can feel quite unwell for up to 48 hours.
Review date 12/10/2016
Page 7Specialist
of 15 Team if concerned
Refer to Diabetes
7. TRAINING REQUIREMENTS
All staff involved in clinical care of inpatients who have diabetes should have read this guideline
and may have further educational input via DIPPIE. PHT staff will be informed of this guideline
and may cascade down to junior staff and students
8. REFERENCES AND ASSOCIATED DOCUMENTATION
1) Diabetes UK (2011) [online] Monitoring Your Health / Glucose Levels. www.diabetes.org.uk
TEL: 020 73231531
2) British National Formulary 60. Section 6.1, Drugs Used In Diabetes. BMJ Group. London
3) Turner H and Wass JA (2007). Oxford Handbook of Diabetes. Oxford University Press.
Oxford
4) Drucquer MH & McNally P (1998) Diabetes Management Step by Step Blackwell Science.
London, Oxford
5) Bailey C and Feher MD (2009). Diabetes Therapies,Treating hyperglycaemia. MedEd UK
Ltd. Halesowen
9. EQUALITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably
practicable, the way we provide services to the public and the way we treat our staff reflects
their individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly
Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They
are beliefs that manifest in the behaviours our employees display in the workplace.
Our Values were developed after listening to our staff. They bring the Trust closer to its vision
to be the best hospital, providing the best care by the best people and ensure that our patients
are at the centre of all we do.
We are committed to promoting a culture founded on these values which form the ‘heart’ of our
Trust:
Respect and dignity
Quality of care
Working together
No waste
This policy should be read and implemented with the Trust Values in mind at all times.
Hypoglycaemia Management of the Adult Inpatient with Diabetes Issue 2 13/10/2014
Review date 12/10/2016
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Review date 12/10/2016
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10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS
Minimum requirement to be
monitored
Lead
Management of patients
with diabetes who are
suffering from
hypoglycaemic episodes
Ward nursing
staff, ward
doctors, &
specialist
diabetes team
Unfavorable hypoglycaemia
management issues.
Specialist
diabetes team
Management of
hypoglycaemia
Specialist
diabetes team
Tool
Daily diabetes
ward rounds
Adverse incident
reporting & ward rounds
Audits
Frequency of Report
of Compliance
Daily
Reporting arrangements
Policy audit report to:

Quarterly
Annual
Specialist diabetes team
Specialist diabetes team
Policy audit report to:

Lead(s) for acting on
Recommendations
Specialist diabetes team
Specialist diabetes team
Policy audit report to:
Specialist diabetes team
 Specialist diabetes team
This document will be monitored to ensure it is effective and to assurance compliance.
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Review date 12/10/2016 Page 10 of 15
Appendix A
Equality Impact Screening Tool
To be completed and attached to any procedural document when submitted to
the appropriate committee for consideration and approval for service and policy
changes/amendments.
Stage 1 - Screening
Title of Procedural Document: Hypoglycaemia management for the Adult Inpatient with Diabetes
Date of assessment
8th April 2011
Responsible
Department
Academic
Department of
Diabetes and
Endocrine
Name of person
completing
assessment
Anita Thynne.
Job Title
Diabetes Specialist
Nurse
Does the policy/function affect one group less or more favourably than another on the basis
of :
Yes/No
 Age
No
 Disability
No
Comments
Learning disability; physical disability; sensory
impairment and/or mental health problems e.g.
dementia
 Ethnic Origin (including gypsies and travellers)
No
 Gender reassignment
No
 Pregnancy or Maternity
No
 Race
No
 Sex
No
 Religion and Belief
No
 Sexual Orientation
No
If the answer to any of the above questions is
NO, the EIA is complete. If YES, a full impact
assessment is required: go on to stage 2, page 2
More Information can be found be following the link
below
www.legislation.gov.uk/ukpga/2010/15/contents
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Stage 2 – Full Impact Assessment
What is the impact
Level of
Impact
Mitigating Actions
(what needs to be done to
minimise / remove the impact)
Responsible
Officer
Monitoring of Actions
The monitoring of actions to mitigate any impact will be undertaken at the appropriate level
Specialty Procedural Document:
Specialty Governance Committee
Clinical Service Centre Procedural Document: Clinical Service Centre Governance Committee
Corporate Procedural Document:
Relevant Corporate Committee
All actions will be further monitored as part of reporting schedule to the Equality and Diversity
Committee
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Appendix B
Checklist for the Review and Ratification of Procedural Documents and
Consultation and Proposed Implementation Plan
To be completed by the author of the document and attached when the document is
submitted for ratification: a blank template can be found on the Trust Intranet
CHECKLIST FOR REVIEW AND RATIFICATION
TITLE OF DOCUMENT BEING REVIEWED:
1
2
4
Is the title clear and unambiguous?
Yes
Will it enable easy searching/access/retrieval??
Yes
Is it clear whether the document is a policy, guideline, procedure,
protocol or ICP?
Yes
Introduction
6
Is there a standard front cover?
Yes
Is the document in the correct format as per Policy for the
Development and Management of Procedural Documents?
Yes
Does the scope include the paragraph relating to ability to comply,
in the event of a infection outbreak, flu pandemic or any major
incident?
Yes
Are the roles and responsibilities clearly explained?
Yes
Does it fulfill the requirements of the relevant NHSLA Risk
Management Standard? (where applicable)
Yes
Evidence Base
Does the document identify which committee/group has approved
it?
Yes
Is the Ratification Checklist complete overleaf
Yes
Are minutes of ratification committee attached showing ratification?
Yes
Process to Monitor Compliance and Effectiveness
Yes
Dissemination and Implementation
Is a completed proposed implementation plan attached?
7
Yes
Review Date
Is the review date identified?
6
Yes
Approval Route
Are there measurable standards or KPIs to support the monitoring
of compliance with the effectiveness of the document?
7
Yes
Content
Is the type of evidence to support the document explicitly
identified?
5
COMMENTS
Title
Are reasons for the development of the document clearly stated?
3
YES/NO
N/A
Yes
Equality and Diversity
Is a completed Equality Impact Assessment attached?
Yes
Hypoglycaemia Management of the Adult Inpatient with Diabetes Issue 2 13/10/2014
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If answers to any of the above questions is ‘no’, then please do not send it for ratification
Checklist for the Review and Ratification of Procedural Documents
and
Consultation and Proposed Implementation Plan
CONSULTATION AND PROPOSED IMPLEMENTATION PLAN
Contact Details
Name and details of key person
developing information and
responsible for review
Development Team and Peer
Review
Groups /committees / individuals
involved in the development and
consultation process
Name
Anita Thynne
Job Title
Diabetes specialist nurse
Department
Diabetes and endocrinology
CSC/Location
Medicine
Telephone
Ext 6260
Email
[email protected]
(a) Anita Thynne Lead Inpatient Diabetes Specialist Nurse
(b) peer reviewed by Diabetes Specialist Nursing team
(c) peer reviewed by Diabetes/Endocrinology Consultant team
(d) Badrriyya Mohamedali Rotational CHAT pharmacist
Implementation Plan
Author(s)
This should be signed by the main
author
What training is
required to
support
implementation?
Education of nurses by the Diabetes team and/or
pharmacy regarding change in policy and practice.
Outline any
additional
activities to
support
implementation
Printing of new treatment algorithm cards to reflect
change in practice which will be placed in each
orange hypo-box.
Name
Posters to be displayed in treatment rooms
highlighting change in policy.
Job Title
Signature
Anita Thynne
Lead Inpatient
Diabetes
Specialist Nurse
If, as the author, you are happy that the document complies with Trust policy, please sign above and send the document,
with this paper, with the Equality Impact Assessment to the chair of the committee/group where it will be ratified. To aid
distribution all documentation should be sent electronically wherever possible.
Name of Ratification Committee
Formulary and Medicines Group
Date of Ratification
(minutes enclosed)
19th September 2014
Name/Signature
of Chair
Dr Mike Stewart
Once the committee/group is happy to ratify this document, would the chair please sign above and send the policy together
with this document, the Equality Impact Assessment, and the relevant section of the minutes to the Risk Analyst. To aid
distribution all documentation should be sent electronically wherever possible.
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