Improving Accuracy and Safety of Inpatient Hypoglycemia Workup

Improving Accuracy and Safety of Inpatient Hypoglycemia Workup Luis Arzeno, MD, Kimberly Lessard, DO, Eric Shiffrin, MD Thomas Jefferson University Hospital, Philadelphia, PA. Problem Definition Intervention Glucose metabolism is a complex process consisting of In reviewing data from hypoglycemia evaluations several physiologic mechanisms that function to regulate performed within our institution it is appears that the serum glucose levels and maintain them within a fairly workup is often incomplete or yields uninterpretable narrow range in healthy individuals. Hypoglycemia is results. characterized by a reduction in plasma glucose While this data is limited and represents a very small concentration to a level low enough, typically less than subset of patients, it is supportive of the need for a 60 mg/dL, to cause symptoms or systemic effects, standardized institutional ‘hypoglycemic diagnostic classically adrenergic stimulation or altered mental Fig 3. protocol’ that will allow for staff to obtain all relevant status. Hypoglycemia is most frequently seen in patients laboratory data needed to complete the diagnostic Next Steps and Lessons Learned with diabetes following insulin injection or intake of oral workup without delaying treatment. We are confident hypoglycemic agents. In the patient without diabetes, that implementation of this simple, user-friendly and hypoglycemia is much less common and often warrants To improve patient safety and diagnostic value of testing, we cost-effective protocol will lead to improved patient propose a provider-driven protocol for testing needed in evaluation further investigation to determine the cause. outcomes and institutional quality measures. of true hypoglycemia. The narrow investigative window in such Hospitalized patients are high risk for hypoglycemia instances, while blood glucose is still low prior to temporizing because acute and chronic illness can cause altered Measurement and Results measures, often limits the opportunity to obtain the appropriate counterregulatory responses and the development of diagnostic testing. It is critically important to confirm that the plasma glucose is indeed low (<60 mg/dL). Serology for additional life-threatening sequelae. Controlling blood glucose in In review of charts of 11 patients recently admitted to hospitalized patients is important as both hyperglycemia testing should be obtained simultaneously for use/analysis if Thomas Jefferson University Hospital (TJUH) for whom hypoglycemia is confirmed. Whipple’s triad of low plasma glucose, and hypoglycemia are associated with increased cost, a complete biochemical evaluation of hypoglycemia was symptoms of hypoglycemia at the time of the low glucose, and length of stay, morbidity and mortality. Avoidance and obtained: symptom relief with treatment of hypoglycemia should also be recognition of hypoglycemia is essential to patient safety confirmed on all patients. and studies have confirmed higher mortality rates with • 2/11 (18%) of evaluations yielded clinically significant data, 82% of initial testing was inconclusive (Fig 1.) Such additional laboratory testing is directed at evaluation for spontaneous rather than iatrogenic hypoglycemia. potential hormone and metabolic imbalances, toxic ingestions, Therefore, hypoglycemia of unclear cause may be viewed • 1/11 (9%) of patients for whom the workup and/or enzymatic defects. This can be done via immediate blood as a biomarker systemic disease and mandates was performed had true hypoglycemia (<60ngdL) draw of at least two gold-top tubes and labs ordered via protocol appropriate investigation to determine the etiology. • 4/11 patients (36%) lacked confirmatory blood (as below). glucose levels (Fig 2) Advanced testing, as included in our proposed order set, should include the following: Aims For Improvement • Basic Metabolic Panel (plasma glucose, electrolytes) • Plasma insulin levels, Pro-insulin levels, C- It is the aim of our quality improvement project to create peptide levels a standardized method to appropriately assess and • Serum lactate and ketones (beta-hydroxybutyrate treat hypoglycemia in the inpatient setting such that the where available), Urine ketones. needed components of the diagnostic evaluation can be • Thyroid, adrenal (random cortisol), liver function tests obtained in an expedited, cost-effective and patient • We recommend obtaining both TSH and Free T4 safety-oriented manner. We plan to design of an • Cortisol level at the time of hypoglycemia is appropriate inpatient hypoglycemia order set which can be used as Fig 1. Fig 2. if >14 mcg/dL an easily accessible reference and clinical tool. • In almost half of all cases, testing had to be repeated. • Spot sulfonylurea screen (send out) • Toxicology screen (UDS, ethanol, salicylates), as appropriate. (Fig 3.).

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