From the 2023 HVPA National Conference
Erwin Wang MD (NYU Langone Health), Marwa Moussa MD
Iatrogenic hypoglycemia is a common and usually preventable adverse event associated with increased mortality, morbidity, length of stay, readmissions, and healthcare expenditures. Recognizing the impact of iatrogenic hypoglycemia on hospitalized patients, serial quality assessment organizations have developed measures evaluating hospital performance. The Centers for Medicare & Medicaid Services (CMS) has implemented a metric in this area through its Merit-based Incentive Payment System (MIPS) program. Vizient, a consortium of medical centers that facilitates hospital quality assessment and performance improvement, also developed a measure related to iatrogenic hypoglycemia in its safety domain. During the baseline period, NYU Langone Hospital – Brooklyn April – December 2021 had a rate of iatrogenic hypoglycemia of 3.4%, which was poor compared to peer institutions. The goal was to reduce the relative rate of iatrogenic hypoglycemia by 15% during the intervention period of April – December 2022. The run-in period was January – March 2022 while the intervention began.
Numerous risk factors for iatrogenic hypoglycemia included advanced age, decreased renal function, poor appetite, prolonged “nothing per oral” or NPO status, etc. Ultimately, in March 2022, we identified an abnormal Braden score as having the greatest association with iatrogenic hypoglycemia. Our hospital has daily multidisciplinary safety huddles where patients with abnormal Braden scores are discussed in relation to HAPI prevention. Beginning April 2022, we leveraged this setting to review patients with abnormal Braden scores to review if insulin was ordered and, if so, whether there was an opportunity to adjust insulin dosing to avoid iatrogenic hypoglycemia. Primary medical/ surgical teams also evaluated whether our specialized endocrine consultation team for glycemic management needed to become involved to optimize the glycemic regimen. Simultaneously, the nurse practitioner for the consult team reviewed a system list within the EMR comprised of patients with high or severe risk Braden scores.
In the pre-intervention time period, 115 iatrogenic hypoglycemia cases were noted out of 3,392 cases where insulin was administered, patients had a length of stay of two days or greater, and potassium was not elevated to greater than 6.0. This yielded a rate of iatrogenic hypoglycemia of 3.4%. In the post-intervention time period, 86 iatrogenic hypoglycemia cases were noted out of 3,357 cases. This yielded a rate of iatrogenic hypoglycemia of 2.6%, representing a 23.5% reduction.
Our interdisciplinary huddle-based approach was associated with a 23.5% reduction in the rate of iatrogenic hypoglycemia, exceeding our SMART goal target. We attribute the success of this intervention to our intentional approach of leveraging existing resources and infrastructure. Our interdisciplinary safety huddles have been associated with numerous other prior quality improvement achievements. Employing a different approach would have necessitated a reliance on new resources, e.g., a larger glycemic management consultative team, which would have required approval for hiring, recruitment, onboarding, and ramp up. Utilizing a more precise risk stratification tool, e.g., a machine learning model, would have required procurement of statistician and IT availability, a period of validation, a prolonged and challenging IT build, and an extensive rollout with frontline teams. We hope to be able to broaden this initiative to other hospitals within the NYU Langone Health system, recognizing that other campuses now demonstrate a greater opportunity for improvement than our hospital.