Introduction of a “hypo box” into an Irish teaching hospital

Hypoglycaemia is a common side effect of intensive therapy with insulin and with oral hypoglycaemic agents, and is the most feared complication of diabetes management; approximately one in four people with diabetes have a hypoglycaemic episode during their hospital stay (Joint British Diabetes Societies [JBDS] Inpatient Care Group, 2010). This has serious consequences as it delays discharge and is associated with increased mortality; the prevention of hypoglycaemia and its prompt and effective treatment is therefore essential (JBDS Inpatient Care Group, 2010).

Hypoglycaemia constitutes a medical emergency, although most individuals recover completely (Tomky, 2005). The symptoms of hypoglycaemia warn an individual of its onset, and vary considerably between individuals (JBDS Inpatient Care Group, 2010); it can be defined as “mild” if the episode is self-treated and “severe” if assistance by a third party is required (Diabetes Control and Complications Trial Research Group, 1993). 

In the short term, hypoglycaemia induces a spectrum of effects, including cognitive impairment, mood changes and the risk of physical injury; it can lead to transient or permanent cerebral damage (Tomky, 2005). If blood glucose levels fall sufficiently, cognitive dysfunction is inevitable (Evans and Amiel, 2002). Rare but potentially fatal effects of untreated hypoglycaemia include seizures, coma or cardiac arrhythmias (Frier, 2004). Hypoglycaemia should be excluded in any person with diabetes who is acutely unwell, drowsy, unconscious, unable to cooperate, presenting with aggressive behaviour or having seizures (JBDS Inpatient Care Group, 2010). To avoid potential hypoglycaemia, the UK Hypoglycaemia Study Group (2007) recommends 4.0 mmol/L as the lowest acceptable blood glucose level in people with diabetes; the NICE (2004) guidelines recommend the avoidance of hypoglycaemia while maintaining blood glucose control as close to optimum levels as is feasible. 

People experiencing hypoglycaemia require quick-acting carbohydrate to return their blood glucose levels to the normal range. The quick-acting carbohydrate should be followed up by giving long-acting carbohydrate either as a snack or as part of a planned meal. All individuals experiencing hypoglycaemia should be treated without delay. It is important to try to ascertain the reason for the hypoglycaemia if possible (Table 1) and determine if there is a pattern occurring, in which case insulin or oral hypoglycaemic agents may need to be adjusted.

As a result of ward experience in Beaumont Hospital, Dublin, the authors suggested that the management of diabetes, in particular hypoglycaemia, was suboptimal and that staff were treating hypoglycaemia inadequately.

Research methodology
In an attempt to address the shortfall in the authors’ service, a multidisciplinary insulin prescription committee was set up in 2007 to look at all aspects of care in relation to inpatients with diabetes. One area of diabetes management that was examined was hypoglycaemia, as this was identified as a significant at-risk area. A key risk that was highlighted was the lack of an identified storage area at ward level where the necessary treatment for hypoglycaemia should be readily available. A questionnaire looking at a number of areas relating to hypoglycaemia was developed (Box 1) to ascertain current staff knowledge regarding hypoglycaemia. Staff were asked to fill in the questionnaire “on the spot” to ensure that information was not flawed by staff sharing information.

The multidisciplinary team insulin prescription committee outlined comprehensive and detailed advice on the causes and management of hypoglycaemia (Box 2a) and developed an algorithm of how to manage hypoglycaemia in a variety of clinical situations (Box 2b). A “hypo box” was sourced, which is a box equipped with all the relevant equipment and requirements to treat hypoglycaemia (Figure 1). A list of what should be included in the “hypo box” was devised (Box 3), laminated and put into the box, as was a laminated copy of the guidelines for hypoglycaemia management (Box 2b); a sticker was developed to put on the outside of the box to indicate what it was. The “hypo box” is an innovative solution for the treatment of hypoglycaemia in Ireland, but has been used for a number of years in the UK (Baker et al, 2007).  

The hypoglycaemia guidelines and “hypo box” were launched as part of a general diabetes inpatient initiative and all clinical areas in the hospital were allocated a “hypo box”. Staff were educated regarding the correct treatment of hypoglycaemia and were familiarised with the “hypo box” and shown how to use the equipment within it. They were supplied with a hypoglycaemia recording booklet and were advised to record any episode of hypoglycaemia and what treatment was given. It was suggested that the “hypo box” should be kept in the drug treatment area and could be either free-standing or wall-mounted. Staff were advised to check the “hypo box” daily and restock it once a hypoglycaemic treatment had been given.

A further audit was carried out 6 months after the introduction of the “hypo box” to assess whether knowledge about management and treatment of hypoglycaemia had improved at ward level.

Findings
The results of the initial hypoglycaemia audit performed in 2009 (Table 2) indicated that staff knowledge regarding management of hypoglycaemia was inadequate; in total, 30% of staff thought a blood glucose of ≤3.0 mmol/L indicated a hypoglycaemic episode and 57% stated that ≤4.0 mmol/L indicated hypoglycaemia. Despite the fact that 79.1% of staff indicated that they were aware of the correct treatment for hypoglycaemia, this had not been the clinical experience of the ward diabetes nurse specialist. 

The audit carried out 6 months after the introduction of the “hypo box” in 2010 (Table 3) indicated that knowledge about treatment of hypoglycaemia had somewhat improved: 86.2% of staff were aware how to treat a hypoglycaemic episode correctly compared with 79.1% in 2009. In addition, 65% of staff were aware that they should treat a hypoglycaemic episode when the blood glucose was ≤4.0 mmol/L.

An audit was done to ascertain whether the “hypo box” was being used correctly and checked on a daily basis (Table 4), and the results were disappointing; only 20% of wards were checking their “hypo box” on a daily basis, and only 40% of “hypo boxes” were stocked properly. However, one positive finding was that 93.3% of staff were aware where the “hypo box” was stored on their ward.

Conclusions
Treatment of hypoglycaemia at ward level has improved since the introduction of a “hypo box” onto each ward, but further improvements are needed. Currently education sessions are ward-based and run with small groups of staff, but this is not done on a regular basis. The education covers both management of hypoglycaemia and maintenance of the “hypo box”. Staff are encouraged to re-stock after the “hypo box” has been used, and to check it daily when checking the cardiac arrest trolley. Education sessions need to be prioritised to ensure that staff have the necessary skills to recognise and treat hypoglycaemia. In addition, education needs to be ongoing and repeated at regular intervals to aid the retention of information. The authors plan on delivering education sessions every 6 months to improve the management of hypoglycaemia at ward level. Attendance at education sessions at ward level in the past has been poor because of a high turnover of staff, staff shortages and increased workload; the aim would be to liaise with the ward sisters about the education sessions, involve the clinical practice support nurses and possibly introducing diabetes link nurses.  

Continuous audit of practice is vital to ensure that inpatients with diabetes receive the appropriate standard of care and to ensure that retention of knowledge regarding hypoglycaemia management is maintained. In the near future, the authors plan to re-audit both knowledge regarding management of hypoglycaemia and whether the “hypo box” is being used properly.

Acknowledgement
The authors would like to thank the Beaumont Hospital Insulin Prescription Committee for their contribution to this article and for helping to manage diabetes more efficiently in our hospital.