Hypoglycaemia in hospital – How to prepare your patients

Hospitals need to be more aware of hypoglycaemia (also known as a hypo), after recent figures showed that one in five inpatients with diabetes have a hypoglycaemia episode during their hospital stay. A diabetes specialist nurse and practice nurse offer their perspectives

Figures from the recent National Diabetes Inpatient Audit show more than one quarter (27%) of inpatients with Type 1 diabetes had a severe hypos during a hospital stay, with the highest proportion (30 per cent) of episodes taking place between 5 a.m. and 9 a.m.

Hypoglycaemia occurs when the blood glucose level of someone with diabetes is too low, usually below 4mmol/l. It can happen for a number of reasons, including missing meals, not having enough carbohydrates or taking more insulin than needed.

If a hypoglycaemia episode is not treated, it could lead to blurred vision, confusion and seizures, and severe hypoglycaemia can even lead to loss of consciousness and coma.

Here a practice nurse and diabetes specialist nurse tell you how you can prepare your patients with diabetes for their hospital stay.

THE PRACTICE NURSE PERSPECTIVE

Did you know that one in five people with diabetes will experience a hypoglycaemic event whilst in hospital? This is one of the findings of the annual National Diabetes Inpatient Audit (NaDIA).¹

This highly unsatisfactory statistic (although improved on previous data) serves to underline the need for all health care professionals to be actively involved in striving to educate people with diabetes, their families, carers and fellow healthcare and allied professionals in the avoidance of hypoglycaemia.

As practice nurses, we are ideally placed to give such effective education and management around hypoglycaemia avoidance to those at risk.

Equipping and empowering the person with diabetes (PWD) with the necessary information, skills and tools to self-manage their own condition to include hypoglycaemia avoidance, is fundamental in delivering good diabetes care. It is important to remember that on average, people with diabetes spend only three hours a year at most with a healthcare professional. For the remaining 8,757 hours, they manage their diabetes themselves² and this can include episodes while in hospital, as often a person with diabetes might be an inpatient in an area where there is limited specialised diabetes knowledge, indeed 28% of hospitals currently have no diabetes inpatient nurses.¹

Hypoglycaemia is any abnormally low plasma glucose concentration that exposes the person to potential harm. This is widely recognised as a threshold plasma glucose value <4.0 mmol/L. It has an effect on cognitive function and unless treated promptly can result in coma and death.³

Risk factors for hypoglycaemia include the following:

• Inadequate food intake, to include delayed or missed meals
• Increased physical activity
• Too much insulin or sulphonylurea
• Problems with insulin injection sites/technique
• Inappropriate timing of insulin injection
• Early pregnancy
• Tight glycaemic control
• Terminal illness
• Malabsorption
• Alcohol
• Impaired renal function
• Breastfeeding

Many of these risk factors can be avoided or minimised and certainly the patients with diabetes that we are caring for need to be fully aware of those applicable to them. What follows is a list of the essential educational guidance around hypoglycaemia that we should be routinely delivering in primary care.

1. KNOWING THE RISK OF HYPOGLYCAEMIA

This may seem rather obvious but always consider the basics first!

It is imperative that all persons taking medications that could cause hypoglycaemia are aware of their risks and indeed what hypoglycaemia is. Such medications are: Insulin, sulfonylureas and glinides. This knowledge should also be extended to family members and carers especially with regards to signs, symptoms and management.

2. KNOWING THE TYPE OF MEDICATION TAKEN

Medication errors are not uncommon in hospital, and NaDIA¹ highlights that two out of five inpatient drug charts showed medication errors. This can be compounded if patients are unclear when reporting which medications they take, especially with insulin when there needs to be clarity on the product, dosage, strength and timing of the insulin. Alarmingly, almost half of inpatients treated with insulin had a medication error related to their insulin.¹ Insulin passports⁴ can be effective in facilitating the safe prescribing of insulin – providing the passport has been kept up to date. Healthcare professionals should encourage the maintenance of up to date insulin passports and encourage PWD to carry them with them at all times. For planned hospital admissions, PWD should be encouraged to take their insulin(s) into hospital with them.

3. UNDERSTANDING THE ACTION OF AND EFFECTS ON MEDICATION

‘No medication without information!’ This is particularly pertinent to medications that may cause hypoglycaemia. It is important for those taking such medications to understand their action and what might affect them, for example, reduced appetite or missed meals. NaDIA1 showed that inpatient perception of the suitability of both meal choice (54%) and timing of meals (63%) has declined since the last audit. PWD need the knowledge and confidence to safely reduce their doses of medications if their dietary intake should lower, meals are missed or know what to do if normal doses of medication have been taken and then meals have been less than expected or missed.

4. AVOIDING OVERTREATMENT

People taking potentially hypoglycaemia-inducing agents should be prescribed the smallest effective dose. On initiation, it is important to titrate doses cautiously based on capillary blood glucose readings, and review regularly. Never forget that sometimes doses of medication need to be reduced or stopped. This is particularly relevant to the frail and elderly who might be losing appetite and weight. A lowered HbA1c might ‘tick the QOF box’⁵ but always consider if the person is being over medicated. The use of appropriate individualised targets is integral to ensuring hypoglycaemia is avoided.^6–8 Being an inpatient when already potentially being over treated will only to serve to heighten the risk of hypoglycaemia.

5. TIMING OF MEDICATION/INSULIN

This is can be particularly problematic in hospital when meals might be unpredictable and thus the timing of bolus and mixed insulins in particular needs to be carefully considered. Those on mix insulin need to be able to ensure that there is there is the facility to have a bed time snack to avoid nocturnal hypoglycaemia. It was noted in NaDIA¹ that the highest proportion of severe hypoglycaemic episodes took place between 05:00 and 08:59am (30 per cent). It might be advantageous to take some suitable bedtime snacks into hospital or to ask relatives to bring in.

6. BLOOD GLUCOSE TESTING

Access to self-blood glucose monitoring equipment is essential for those at risk of hypoglycaemia. It is important that those who are at risk have equipment that meets the appropriate ISOS standards,9 and know how to interpret their results especially in terms of medication adjustment. It might be appropriate for persons with diabetes to take their own blood glucose monitoring equipment into hospital with them.

7. REVIEWING INSULIN INJECTION SITES AND TECHNIQUE

Changing injection sites from areas of lipohypertrophy into areas of healthy skin can result in hypoglycaemia as insulin is then more effectively absorbed. This could occur in hospital when perhaps it might be necessary for a health care professional to take over the administration of insulin. Good practice is to ensure that no one taking insulin develops lipohypertrophy in the first instance, with review of insulin injection technique and site rotation at every diabetes consultation.¹⁰

8. BEING AWARE OF THE SIGNS AND SYMPTOMS OF HYPOGLYCAEMIA

Should hypoglycaemia occur, those with diabetes, their family and carers need to be aware of the possible signs and symptoms so that they can self treat their hypoglycaemia or in the case of patients in hospital, alert hospital staff in a timely manner. Symptoms vary from person to person and may even vary with each episode.

Signs and symptoms include:

• Sweating
• Trembling
• Feeling of hunger
• Anxiety
• Irritability
• Pallor
• Palpitations
• Tingling lips
• Low concentration
• Vagueness
• Confusion
• Convulsions
• Coma

9. EFFECTIVE TREATMENT

Knowledge of prompt effective treatment is vital for PWD and as importantly for their families and carers. Taking appropriate hypoglycaemia treatments into hospital could be beneficial. Treatment when conscious and able to swallow is to give 15-20g fast acting carbohydrate such as:

• Glucojuice^TM (60ml)
• Cold sweet drink e.g. fruit juice (150-200ml) (unless on a low potassium diet)
• 5-7 Dextrose tablets or 4-5 Glucotabs
• 150 ml (small can) non-diet fizzy drink. Check carbohydrate content since many manufacturers have reduced the sugar content of their products to avoid the sugar tax
• 4 large jelly babies
• 3-4 heaped teaspoons sugar in water

10. KNOWLEDGE OF SICK DAY RULES

This article has focused on the prevention of hypoglycaemia but there are other complications to consider when PWD are unwell and possibly in hospital. These include diabetic ketoacidosis (DKA) and hyperosmolar hyperglycaemic state (HSS). Around 1 in 25 inpatients with Type 1 diabetes develop DKA during their hospital stay (4.4%) and around 1 in 500 inpatients with Type 2 diabetes develop HHS during their hospital stay (0.2%). It is therefore equally important that PWD understand the effects and what to do in the event of raised glucose levels which are common when unwell. The avoidance of an acute kidney injury is also pertinent in times when dehydration might occur and in such episodes PWD need to be aware that certain medications including, metformin, angiotensin-converting-enzyme inhibitors, sodium-glucose co-transporter 2 inhibitors (SGLT2s) and non-steroidal anti-inflammatories need to be suspended. SGLT2s should also be stopped prior to surgical procedures.¹¹

Primary care clearly has a pivotal role in ensuring that PWD are fully educated and confident in managing their own diabetes and reducing their own risks of hypoglycaemia. Knowledgeable patients who are engaged with healthcare professionals can only enhance outcomes.

THE DIABETES SPECIALIST’S PERSPECTIVE

Advice for practice nurses

Both hypo- and hyperglycaemia are associated with adverse outcomes in hospital, including death. Hospitals should keep people safe, reduce length of stay, minimise risk of infection and falls and reduce the risk of hypos and hyperglycaemia. However, changes in timings of medication and food, periods of starvation, as well as changes in portion sizes of meals and availability of snacks can leave people at risk of hypoglycaemia during their stay.

Hypoglycaemia is generally defined as a blood glucose below 4mmol/l and a severe hypo is defined by a blood glucose below 3mmol/l.¹ There are some patients who will feel a low blood glucose at a higher level, as their glucose control has been invariably poor. Ward staff should ask on admission at what level the person feels low so this can be documented in the care plan. Age should be taken into account, as glucose targets for the older person will be higher in general.

The American Diabetes Association¹² classifies hypoglycaemia as:

• Blood glucose <3.9mmol/l – requires fast acting carbohydrate and potentially dose adjustment of insulin or oral agents

Blood glucose <3mmol/l is classified as severe hypoglycaemia. This may have implications on the individual’s ability to drive and may also require third party assistance.

Most hospitals classify hypoglycaemia as between 3.5-4mmol/l and will have appropriate treatment logarithms in place.

The National Diabetes Inpatient Audit (NaDIA)¹ reported:

• The prevalence of hypoglycaemia in hospital has fallen from 2011 to 2016 from 26% to 20%. However, this still means that 20% of in patients had a hypoglycaemic event during their stay
• 27% of patients with Type 1 diabetes had a severe hypoglycaemic event during their admission
• The key time for hypoglycaemic episodes seems to be 05.00-09.00 which is suggestive of overnight hypoglycaemia.
• Patients who test their own blood glucose in hospital are more likely to report a severe hypoglycaemic event. They probably test at the time they feel low and report to staff.

Surgical procedures are often accompanied by a period of starvation and/or reduced food and fluid intake which can impact on diabetes control. Routines are changed and staff understanding of hypoglycaemia management in hospital can be variable. Intravenous insulin is often used during and after surgery, which could lead to a much lower blood glucose level than normally experienced for some patients.

Evidence suggests that primary care clinicians often fail to identify high risk patients before surgery and do not provide peri-operative interventions to control HbA1c levels.¹³ When referring a person with diabetes for an elective surgical procedure it is worth remembering that the HbA1c target prior to elective surgery is below 69mmol/mol. It would be advisable to help the person get to that target prior to surgery rather than have the surgery postponed due to poor diabetes control. A higher than acceptable HbA1c does not preclude people from hypoglycaemia in hospital – often they will feel a lower glucose more acutely as their control is normally poor.

How can we prepare our patients for surgery and minimise the risk of hypoglycaemia?

The JBDS guideline (revised 2016) includes the following recommendations for primary care clinicians to minimise the risks of hypo and hyperglycaemia in elective surgery:¹⁴

1. A discussion with the patient prior to referral, particularly related to the risks associated with a surgical procedure and other co-morbidities the person may have. These should be included in the referral letter.

2. Try to optimise glucose control as much as possible – HbA1c target should be below 69mmol/mol. However, there may be reasons why this target is not achievable in the time frame and these should be outlined in the referral. If the person is not currently under secondary care review, a referral to your local team may be useful. Introducing insulin therapy prior to surgery to improve glucose control for those on oral hypoglycaemic agents may be useful.

3. If the person is struggling to recognise their hypoglycaemia symptoms then a referral to your secondary care diabetes team is also advisable.

What does the person with diabetes need to know prior to admission?

It may be useful to mention the following to the patient prior to admission:

1. Timings of meals will be different, as well as the choice and portion sizes. For patients who are carbohydrate counting they can alter their doses accordingly – for those on fixed doses, particularly of a mixed insulin, they may need a dose reduction if their appetite is reduced. There may be a prolonged period of fasting – most hospitals will have guidelines in place to advise patients about the reduction of insulin doses and also reduction/omission of oral agents prior to a surgical procedure. They may require intravenous insulin depending on the length of the procedure and the timing of the surgery.

2. Levels of understanding of diabetes will vary across hospital staff. Let the ward staff know at what level they would consider themselves to be hypoglycaemic and how they would normally treat this. All wards and departments will have hypoglycaemia treatments available, but the person may not be able to communicate this effectively after an anaesthetic.

3. Always have a copy of their prescription and medication with them. Some hospitals will allow patients to self-medicate and check their own blood glucose. This can be addressed at the surgical pre-assessment visit.

4. Pre-operative advice may be available from your secondary care diabetes team. This is often posted on hospital intranet sites.

5. They can ask to see a member of the Diabetes Team as part of their admission – this is usually the Diabetes In Patient Specialist Nurse (where available).

CONCLUSION

The aim of any planned surgical procedure is to keep the person safe, treat the condition successfully and have a good outcome. Diabetes can complicate the procedure, due to unexpected changes in blood glucose and the increased risk of post-operative infection. Hypoglycaemia is an unpleasant and potentially (albeit rare) life threatening complication of diabetes. The better prepared the person with diabetes then hopefully the more satisfactory their experience, with less likelihood of having a hypoglycaemic episode in hospital.

Resources

Diabetes UK has launched a new Improving Inpatient Care programme: to find out more visit www.diabetes.org.uk/inpatientcare or get in touch via email to inpatientcare@diabetes.org.ukYou can also find information about illness and surgical procedures at:TREND-UK http://trend-uk.orgFor information on what patients with type 1 or type 2 diabetes should do when they are unwell (sick day rules) visit: Leicestershirediabtes.org.uk http://www.leicestershirediabetes.org.uk/438.html

References

1. The National Diabetes Inpatient Audit, 2016 http://digital.nhs.uk/catalogue/PUB23539

2. Diabetes UK Diabetes, Education and Self management https://www.diabetes.org.uk/professionals/resources/shared-practice/diabetes-education

3. Amiel SA, Dixon T, Mann R, and Jameson K. Hypoglycaemia in Type 2 diabetes, Diabetic Medicine 2008;25(3): 245-254

4. National Patient Safety Agency 2011 The adult patient’s passport to safer use of insulin http://www.nrls.npsa.nhs.uk/resources/?EntryId45=130397

5. NHS England. 2016/17 General Medical Services (GMS) contract Quality and Outcomes Framework (QOF) Guidance for GMS contract 2016/17 http://www.nhsemployers.org/~/media/Employers/Documents/Primary%20care%20contracts/QOF/2016-17/2016-17%20QOF%20guidance%20documents.pdf (Last accessed 02.11.17)

6. American Diabetes Association. Standards of medical care in diabetes—2017. http://care.diabetesjournals.org/content/diacare/suppl/2016/12/15/40.Supplement_1.DC1/DC_40_S1_final.pdf

7. NICE [NG17]. Type 1 diabetes in adults: diagnosis and management, 2015. https://www.nice.org.uk/guidance/ng17

8. NICE [NG28] Type 2 diabetes in adults: management, 2015 (updated 2017). https://www.nice.org.uk/guidance/ng28

9. TREND (January 2017) Blood Glucose Monitoring Guidelines A consensus document Available at http://trend-uk.org/wp-content/uploads/2017/02/170106-TREND_BG_FINAL.pdf (Last accessed 02.11.17)

10. Forum for Injection Technique UK. The UK Injection and infusion technique Recommendations 4th Edition, 2016 http://www.fit4diabetes.com/files/4514/7946/3482/FIT_UK_Recommendations_4th_Edition.pdf

11. Medicines and Healthcare products Regulatory Agency. SGLT2 inhibitors: updated advice on the risk of diabetic ketoacidosis, 2016. https://www.gov.uk/drug-safety-update/sglt2-inhibitors-updated-advice-on-the-risk-of-diabetic-ketoacidosis

12. American Diabetes Association Glycaemic Targets Diabetes Care 2017 January;40 supplement 1 p48-56

13. NICE [NG45] Routine pre-operative tests for elective surgery, 2016 https://www.nice.org.uk/guidance/ng45

14. JBDS-IP Management of adults with diabetes undergoing surgery and elective procedures: improving standards. Revised March 2016 NHS Diabetes