A young child was brought to the emergency department by her parents due to symptoms of abdominal pain, nausea, and vomiting. Following a history of increased thirst, frequent urination, and unexplained weight loss, she was diagnosed with new-onset type 1 diabetes. Medical tests showed high glucose levels, low bicarbonate levels, and elevated A1c levels. Treatment included insulin administration and intravenous fluids. Additionally, rapid-acting insulin was given to cover carbohydrate intake at lunch.
Low blood sugar, or hypoglycemia, can occur in individuals with diabetes when their blood sugar levels drop to dangerous levels. Symptoms may include shakiness, sweating, dizziness, confusion, and in severe cases, loss of consciousness.
The “15 rule” for diabetes refers to a common strategy for treating low blood sugar. The rule involves consuming 15 grams of carbohydrates to raise blood sugar levels. Examples of foods that contain approximately 15 grams of carbohydrates include: 4 oz of fruit juice, 1 tablespoon of honey, or 4 glucose tablets.
If a person with diabetes experiences symptoms of hypoglycemia, they should follow the 15 rule by consuming 15 grams of carbohydrates, waiting 15 minutes, and then checking their blood sugar levels again. If blood sugar levels remain low, the process may need to be repeated until levels are within a safe range.
It is important for individuals with diabetes to always carry a source of fast-acting glucose with them, such as glucose tablets or a small bottle of fruit juice, to quickly address episodes of low blood sugar. Seeking medical attention may be necessary if symptoms do not improve or if blood sugar levels continue to drop.
Early recognition
Later on, the child’s mother called expressing concern as the child was behaving oddly. It was suspected that the child was experiencing acute hypoglycemia. After a glucose test revealed low levels, vital signs were checked, and the Rule of 15 was applied to stabilize glucose levels before providing a snack.
Hypoglycemia, or low blood sugar, can be a serious condition that requires prompt attention. Symptoms may include confusion, shakiness, sweating, and in severe cases, seizures or loss of consciousness. It’s important to monitor blood sugar levels regularly, especially in individuals who are at risk for hypoglycemia.
Education
Nurses provided education on hypoglycemia symptoms and treatment to the family. Rapid-acting carbohydrates were administered until glucose levels returned to normal. Severe cases might require the use of glucagon, and caregivers were educated on how to manage such situations. It is important for family members to be able to recognize the signs of hypoglycemia and know how to respond quickly to prevent complications. Education on proper nutrition and lifestyle changes may also be provided to help prevent future occurrences of hypoglycemia.
Outcome
Following stabilization of the child’s condition, she was discharged with instructions on the Rule of 15.
*Names have been changed for privacy.
Vanessa Lee Hedge works as an assistant professor at Radford University School of Nursing in Radford, Virginia.
American Nurse Journal. 2023; 18(3). Doi: 10.51256/ANJ032340
Key words: hypoglycemia, type 1 diabetes, pediatric patients, Rule of 15
In case of low blood sugar, follow the 15-15 rule:
- Consume 15 grams of carbohydrates, then wait for 15 minutes.
- Check blood sugar levels again. Repeat the process if levels are still below 70 mg/dL.
- Continue until blood sugar levels return to normal.
- After treating low blood sugar, have a balanced snack or meal containing protein and carbs.
Remember:
- Check blood sugar regularly, especially when at risk of low levels.
- You may need less than 15 grams of carbs if you are a child.
Foods to treat low blood sugar
During low blood sugar treatment, opt for quickly absorbing sugars. Keep a source of sugar at home, such as juice, candy, or glucose tablets. Avoid fiber and fatty foods as they can slow down sugar absorption.
Treating severely low blood sugar
Severe hypoglycemia requires immediate action with injectable glucagon. Familiarize yourself with its administration procedure before an emergency.
Seek medical help right away
Prevention
Regularly monitor blood sugar levels to prevent hypoglycemia. Share any patterns with your doctor for necessary treatment adjustments.
Things for loved ones to know
Ensure those around you know how to handle low blood sugar incidents. Educate friends, family, and caregivers on symptoms, testing, and required actions. Keep a glucagon kit accessible for cases of severe hypoglycemia.
Confusion or cognitive impairment can hinder your ability to treat low blood sugar.
One key intervention to improve adherence to a hypoglycemia protocol is to provide comprehensive training to patients, caregivers, and healthcare providers. This training should include detailed information on recognizing symptoms of low blood sugar, proper testing techniques, and the necessary steps to take in case of an emergency.
Another important intervention is to create a personalized hypoglycemia management plan for each individual. This plan should take into account the person’s lifestyle, medication regimen, and other medical conditions to ensure the most effective and tailored approach to preventing and treating low blood sugar episodes.
Regular monitoring and follow-up with healthcare providers is essential in promoting adherence to a hypoglycemia protocol. This ensures that any changes in the person’s condition or medication regimen are addressed promptly, and that any necessary adjustments can be made to the management plan.
Abstract
Background. An evidence-based protocol for managing hypoglycemia was developed to ensure effective treatment. Timers can assist in reminding staff to check a patient’s blood glucose post-treatment.
Objective. Two interventions were tested to enhance adherence to the protocol.
Conclusion. Timers prove to be an effective tool in reminding staff to recheck a patient’s blood glucose after treating hypoglycemia.
Delay in hypoglycemia treatment can have severe consequences.
Challenges in Hypoglycemia Management
In addition to poor protocol adherence, other challenges in managing hypoglycemia in hospitals include staff turnover, lack of standardized protocols, and communication issues among healthcare providers. These factors can contribute to the occurrence of hypoglycemia episodes and hinder effective treatment.
Importance of Team Collaboration
Collaboration among healthcare providers, including nurses, physicians, pharmacists, and dietitians, is crucial in effectively managing hypoglycemia. Regular communication and teamwork can help ensure timely administration of medications, monitoring of blood glucose levels, and adherence to treatment protocols.
Patient Education and Empowerment
Empowering patients with knowledge about hypoglycemia symptoms, prevention strategies, and treatment options can also play a significant role in reducing the occurrence of episodes. Patient education programs should be implemented to enhance awareness and promote self-management of hypoglycemia.
Technology Solutions
Utilizing technology, such as electronic medical records and glucose monitoring systems, can improve the accuracy of data collection, facilitate timely interventions, and track outcomes related to hypoglycemia management. Incorporating technology into healthcare practices can enhance efficiency and reduce the risk of errors.
Continuous Quality Improvement
Continuous monitoring, evaluation, and adjustment of hypoglycemia management practices are essential for maintaining high standards of care. Quality improvement initiatives should be ongoing to address any identified gaps, implement best practices, and ensure positive patient outcomes.
Project Design
Process
Poor staff adherence to timely blood glucose rechecks post-hypoglycemia treatment led to a quality improvement project. Despite education efforts, compliance remained low. To address this, recheck timing was adjusted following hypoglycemia identification.
A multidisciplinary approach was adopted to implement interventions aimed at enhancing adherence to the revised protocol.
Sample and Setting
The project was conducted in a 309-bed community hospital in the Midwest.
Methods
A performance improvement team oversaw the project, led by specialists. Units were chosen based on priority needs. Digital timers were utilized to prompt rechecks.
The project monitored compliance with protocol requirements for timely blood glucose rechecks post-hypoglycemia treatment. Staff education for both intervention groups was conducted regularly. Data collection spanned 12 weeks, with compliance measurements based on rechecks done within the specified time frame. Weekly compliance results were shared with unit leadership, consisting of managers and clinical nurse educators. Nurses received reeducation when recheck time frames were not met.
For the timer group, a process flowchart involving PCTs and nurses was developed with timers placed near each blood glucose meter. Proper procedures were followed if low blood glucose levels were identified by a PCT. The nurse conducted the recheck once the timer alerted. The nurse-administered treatment after a PCT identified hypoglycemia and stayed for the recheck.
Blood glucose readings were uploaded for analysis. Results showed better compliance and shorter recheck times for the timer group compared to the PCT group. Noncompliance issues were addressed with staff reeducation to enhance performance.
The institution received Joint Commission Certification for Advanced Inpatient Diabetes Management. Feedback from unit leadership emphasized the need for ongoing data monitoring to improve performance. Weekly reports were sent to unit leadership for review and improvement recommendations.
One identified educational gap was the need to train registry nurses and PCTs floating to project units unfamiliar with the process. Training sessions and badge cards were provided during orientation.
An analysis revealed inaccuracies in report data, prompting a revision in data accuracy before sharing with leadership.
Issues with clock synchronization affected recheck accuracy in the PCT group, highlighting factors influencing compliance rates.
Limitations
Initially piloted with a patient population at higher risk of hypoglycemia, the timer recheck protocol was implemented hospital-wide. Weekly reports continue to be shared with unit leadership.
Conclusion
Treatment and prevention of hypoglycemia are crucial elements in the care standards for diabetes as well as a quality measure by the Joint Commission. The use of timers has proven to be effective in reminding nurses to recheck blood glucose levels, leading to a successful process with an annual compliance rate of 75%.
Duality of Interest
No conflicts of interest were disclosed.
References
- 1. Research by Garg R, Hurwitz S, Turchin A, Trivedi A shows that hypoglycemia, whether with or without insulin therapy, is linked to higher mortality rates in hospitalized patients.
- 2. Campbell K and Braithwaite S study hospital management of hyperglycemia.
- 3. Selig PM, Popek V, Peebles KM focus on minimizing hypoglycemia in hospitalized patients following strict glycemic control protocols.
- 4. Wexler DJ, Meigs JB, Cagliero E, Natha DM, Grant RW investigate the prevalence of hyper- and hypoglycemia among diabetic inpatients.
- 5. American Diabetes Association delves into diabetes care within hospital settings.
- 6. Briscoe VJ, Davis SN analyze hypoglycemia in type 1 and type 2 diabetes, including its physiology, pathophysiology, and management.
- 7. Tomky D focuses on the detection, prevention, and treatment of hypoglycemia in hospitals.
- 8. Carey M, Boucai L, Zonszein J examine the impact of hypoglycemia on hospitalized patients.
- 9. Desouza CV, Bolli GB, Fonseca V explore the relationship between hypoglycemia, diabetes, and cardiovascular events.
- 10. Turchin A, Matheny ME, Shubina M, Scanlon JV, Greenwood B, Pendergrass ML study hypoglycemia and its clinical outcomes in diabetic patients hospitalized in general wards.
- 11. Whitmer RA, Karter AJ, Yaffe K, Quesenberry CP, Selby JV investigate hypoglycemic episodes and the risk of dementia in older patients with type 2 diabetes.
- 12. Van den Berghe G, Wouters P, Weekers F, et al. conduct intensive insulin therapy research in critically ill patients.
- 13. Umpierrez GE, Smiley D, Zisman A, et al. carry out a randomized study on basal-bolus insulin therapy for inpatient management of type 2 diabetes patients.
- 14. Umpierrez GE, Smiley D, Jacobs S, et al. perform a randomized study on basal-bolus insulin therapy for inpatient care of type 2 diabetes patients undergoing general surgery.
Articles from Diabetes Spectrum: A Publication of the American Diabetes Association are presented here with kind permission from the American Diabetes Association.