Managing Inpatient Hypoglycemia

Innovations in Diabetes & Metabolic Care | Fall 2023

At the start of 2023, the Centers for Medicare & Medicaid Services (CMS) implemented additional requirements to its mandatory Hospital Inpatient Quality Reporting Program. Among the changes, health systems must include assessments of hospital harm from severe hypoglycemia and hyperglycemia as part of the new electronic clinical quality measures.

Yumiko Tsushima, MD

Yumiko Tsushima, MD, an Endocrinologist with University Hospitals Diabetes and Metabolic Care Center, discusses challenges specific to managing inpatient hypoglycemia.

“We know that inpatient hypoglycemia leads to increased length of stay, greater in-hospital risk of morbidity and mortality, and increased demand on hospital resources,” says Dr. Tsushima.

“As our health system collects the required CMS data, we will also learn about nationwide trends, which will hopefully trigger interventions to prevent inpatient hypoglycemia.”

Most common in individuals with Type 1 diabetes, hypoglycemia can also affect people with Type 2 diabetes. Additionally, Dr. Tsushima shares that based on a review of their hospital’s inpatient hypoglycemic events, a significant portion of patients who do not have diabetes also develop hypoglycemia. “This population has not been very well studied, so further research is needed to develop methods to prevent nondiabetes-related causes of hypoglycemia,” she says.

The American Diabetes Association (ADA) recommends a target glucose range of 140-180 mg/dL for the management of diabetes mellitus in most hospitalized patients. Generally, symptoms of hypoglycemia occur when blood glucose drops below 70 mg/dL in individuals with diabetes or 55 mg/dL in individuals who do not have diabetes.

Severe hypoglycemia is defined as blood glucose below 40 mg/dL. At this point, patients may become disoriented, lose consciousness or experience seizures. Unless hypoglycemia is reversed promptly, coma or death is possible.

CMS guidelines now require hospitals to document each instance of inpatient blood sugar under 40 mg/dL occurring within 24 hours of the individual receiving insulin or other diabetes medication.

Hypoglycemic Risk Factors

Reducing inpatient hypoglycemia requires an understanding of individual and institutional risk factors.

Individual risk factors include:

• Critical illness or sepsis
• Comorbidities such as kidney or liver failure
• Elevated body mass index (BMI)
• Severity of diabetes mellitus
• Lower caloric intake during hospital stay

Institutional risk factors include:

• Inconsistencies in glucose monitoring
• Incompatible timing of mealtime insulin with food delivery
• Challenges of titrating nighttime insulin
• Prolonged fasting due to surgical or procedural delays

Nutrition-Linked Complications

Medically ordered dietary restrictions, adjustment to different foods and feeling unwell or nauseous can affect patients’ carbohydrate and calorie consumption in the hospital environment. “One of the difficulties when managing inpatient diabetes is that people tend to eat a lot less or not at all during their hospitalization, which makes medication adjustments challenging,” says Dr. Tsushima. “If insulin is not adjusted appropriately for the changes in the patient’s nutritional intake, the risk of hypoglycemia increases.”

For patients who require short-acting mealtime insulin, timing in relation to food intake is important. “Ideally, short-acting insulin should be administered 10 to 15 minutes before the meal,” says Dr. Tsushima. “If the timing is off, and insulin is given after the meal, that increases the risk of the patient developing hypoglycemia.”

Similarly, long-acting insulin needs to be adjusted in the inpatient setting. “Patients with diabetes typically have a bedtime blood sugar check and receive long-acting insulin, which can significantly affect morning glucose levels,” says Dr. Tsushima. “If there is a big drop in blood sugar from bedtime to morning, it usually means that the long-acting dose is too high and should be lowered for the next night.”

The endocrinology team at University Hospitals conducts a weekly review of patients who experience low glucose levels to determine probable causes and communicate findings with the primary care providers. “If we can identify a preventable cause, like the need to adjust short- or long-acting insulin, we send out an email to suggest adjusting the dose,” says Dr. Tsushima.

NPO and Nutrition Complications

According to the National Institutes of Health, up to half of medical patients need to fast for some part of their hospitalization.¹ Patients are frequently placed on nothing-by-mouth orders (NPOs) in preparation for sedation or general anesthesia. The reduced access to food impacts medication delivery, particularly insulin.

“These individuals will be getting regular blood sugar checks, but the challenge is when something unexpected causes a delay to when they are able to return to eating,” says Dr. Tsushima. “As EMR [electronic medical record] capabilities advance, it will be helpful to utilize the system to alert team members in instances of NPO and generate an automatic order to adjust insulin.”

Critically ill patients may need to be started on tube feeds or total parental nutrition (TPN) if they are intubated or otherwise unable to eat by mouth. “Coordinated care is important because hypoglycemia can occur if there is a significant lag before nutrition is started,” says Dr. Tsushima. “When patients are experiencing dangerously low glucose levels, they typically receive an injection of D50 [dextrose 50] to raise their blood sugar quickly.”

Dr. Tsushima notes that D50 is a short-acting solution. While a D50 injection can improve hypoglycemia quickly, it is a treatment meant for patients on insulin therapy. The challenge is preventing hypoglycemia when the cause is not insulin related.

“While ruling out certain conditions that can cause hypoglycemia, we need to think of ways to bridge the gap between the start of NPO and the time it takes to stabilize the patient enough to safely start nutrition,” she says. “Sometimes, we will utilize a glucose drip to maintain euglycemia until the patient can receive stable nutrition.”

The unpredictable nature of acute injury or illness demands collaboration between the primary care team and endocrinologists to manage glucose levels. “We want to take proactive measures to avoid inpatient hypoglycemia, promote healing and prevent risk of subsequent events,” says Dr. Tsushima. “Prevention is crucial and requires a multidisciplinary approach.”

For more information, contact the UH Diabetes and Metabolic Care Center at 440- 860-2353.

1 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8191764/

Contributing Expert:
Yumiko Tsushima, MD
Endocrinology Physician Assistant
University Hospitals Diabetes and Metabolic Care Center
University Hospitals Cleveland Medical Center
Assistant Professor
Case Western Reserve University School of Medicine