Stop Low Blood Sugar” Patient Safety Program

About the Program

Category: Health (Best in Category)

Year: 2017

Hypoglycemia is characterized by low blood sugar levels; “severe hypoglycemia has the potential to cause accidents, injuries, coma, and death” (American Diabetes Association); it is a patient safety event. The national strategic approach to healthcare is the triple aim: care, health, and cost. Designed to address the triple aim, the “Stop Low Blood Sugar” patient safety program includes: (A) medicine-ward pilot and hospital-wide impact studies using the Modified Insulin Therapy Protocol (MITP), (B) the patient-centered education for hypoglycemia prevention, and (C) the cost-saving study to demonstrate the efficacy. A. The Pilot Study focused on the reported patient safety events, specifically tracked the occurrence of hypoglycemic events before and after the implementation of the MITP among hospitalized patients (Bughi et al., 2015). The MITP includes modification of insulin administration time and tailoring the insulin dose for patients with less than 50% of food intake. Hospitalized patients on wards without using the MITP were 3.66 times more likely to have hypoglycemic events compared to those on the MITP. The Impact Study used Point-Of-Care Blood Glucose (finger-stick) results as the outcome measure of the hospital-wide use of the MITP. The hospital-wide average monthly hypoglycemic episodes reduced 45%, from 130 to 71.5, (decreased from 25.12 to 14.47 per 1,000 Hospital‐Bed Days) using the MITP. The ward-based hypoglycemic episodes showed a 34.9% drop. B. Patient/family-centered education (English/Spanish) handouts were designed for safe management of diabetes. Specific actions for hypoglycemia prevention were included according to the results of the field- testing with patients. C. Two methods were used to compute potential cost savings of the MITP implementation based on the decreased hospital stay and the Hospital Engagement Network 2.0 Improvement Calculator. The cost saving using the MITP was estimated to be $1.36 - $2.1 million annually.