Pharmacists Lead Attack On 'Hidden Epidemic' of Hypoglycemia

Marcia Frellick

December 17, 2013

When pharmacists at BJC HealthCare realized that adverse drug events were responsible for 20% of the preventable harm that occurred in their system, they led a multidisciplinary mission to reduce them.

Now, instead of an average 138 such events per month, the system averages "in the 30s," said Paul Milligan, PharmD, medication safety officer at BJC HealthCare in St. Louis, Missouri.

The team has been credited with preventing more than 2100 hypoglycemic events, which saved 8127 inpatient days and more than $7 million in hospital costs.

The protocols that achieved these dramatic results won BJC the 2013 Award for Excellence in Medication-Use Safety at the American Society of Health-System Pharmacists Midyear Clinical Meeting in Orlando, Florida.

The journey started 5 years ago with a hunt for a cause. Pharmacists worked with the hospital's informatics department to track the origin of drug events and were surprised to find that 77% were caused by severe hypoglycemia — a "hidden epidemic," Dr. Milligan said. "It was not on anybody's radar," he told Medscape Medical News.

That revelation presented particular challenges. Hypoglycemia has assorted and complex root causes — from prescribing to drug administration to patient compliance to food issues to equipment variances. Dr. Milligan explained that the population available to study was very large — about a third of the patients in the system had diabetes.

 
It wasn't on anybody's radar.
 

However, "clinicians frequently focus on the primary reason a patient comes to the hospital, and diabetes is often secondary," he said.

Pharmacists teamed up with physicians, nurses, dietitians, and diabetes educators to study the problem at 11 hospitals in the BJC system, and discovered that each hospital had a different primary root cause for the hypoglycemia. At one hospital, the 3 people delivering the food, testing the blood, and delivering the insulin came in at different times, so could not perform their actions simultaneously, which is preferable. At another hospital, admitted patients were getting fewer calories than they did at home, but were receiving the same medication dose, which caused blood sugar to drop, Dr. Milligan said.

Once the root causes were determined, the team developed interventions customized to each hospital. That was one key to BJC's success, he explained: They didn't try to implement one standard list across all the hospitals.

"We took a single-bullet approach. We dealt with the biggest problem at each hospital," and sometimes only on the problem floors, he said. You get a big impact and bigger buy-in if staff can see direct results.

Elizabeth Pratt, DNP, RN, from Barnes-Jewish Hospital, which is part of BJC HealthCare, said some of the problem was a lack of awareness among clinicians about hypoglycemic trends in patients and a lack of automated triggers that would alert clinicians to monitor glucose levels.

"With heightened awareness and an alert system, we're able to recognize those people earlier, have a multidisciplinary discussion with the nurses, pharmacists, and physicians," and ask whether the regimen should be adjusted, she said.

Now that the initial problems are under control, Dr. Pratt has taken over maintenance of the system-wide program. In 2014, the program will be expanded to include the prevention and treatment of hyperglycemia, she reported.

The authors have disclosed no relevant financial relationships.

American Society of Health-System Pharmacists (ASHP) Midyear Clinical Meeting. Presented December 8, 2013.

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