• Implementation of a Pediatric-Based Algorithm to Improve Care of Symptomatic Hypoglycemia

      Arjoon, Amanda V.; Fitzgerald, Jennifer (2021-05)
      Problem & Purpose: Hypoglycemia in childhood is a low frequency, high-risk event that can lead to coma, seizures, and even death. Symptomatic hypoglycemia occurs when plasma glucose levels are low enough to cause signs and symptoms of impaired neurological function, increasing risk of neurogenic sequalae. In the pediatric emergency department at an urban academic medical center in the Mid-Atlantic region, delays in treatment occur due to pediatric-specific barriers including time intensive, weight-based calculations for drug doses and availability of multiple dextrose concentrations. Although there is no national benchmark for comparison, the average time from identification of symptomatic hypoglycemia to treatment on this unit is 35 minutes. The purpose of this quality improvement project was to implement an algorithm for treatment of symptomatic hypoglycemia for pediatric patients between one and five years of age in the proposed setting. Methods: An algorithm was created based on recommendations from the Pediatric Endocrine Society, the American Academy of Pediatrics, and other accredited organizations. Thirty-two small educational sessions with 59 nurses and three physician assistants were conducted over two months to provide education on algorithm use. Anonymous pre- and post-surveys were administered during the educational sessions to assess for improvements in knowledge of evidence-based care for symptomatic pediatric hypoglycemia patients. The primary outcome was to reduce time from symptomatic hypoglycemia identification to enteral or parental treatment. Results: The sample size (N=4) was smaller than expected due to a significantly reduced census on this unit during the COVID-19 pandemic. Three males and one female met inclusion criteria, with a mean age of 2.75 years. The mean time to treatment was reduced to 6.5 minutes. The most observed symptom was nausea, which appeared in all four cases. Nearly 93% of staff demonstrated improved knowledge in caring for pediatric symptomatic hypoglycemic patients through improved survey scores after the educational sessions. Conclusion: Findings suggest that use of a standardized algorithm contributes to reducing the time from identification of symptomatic hypoglycemia to time of treatment. All patients meeting inclusion criteria received interventions consistent with the algorithm. Future directions include expanding implementation of an algorithm to incorporate pediatric patients of all ages.
    • Implementation of Dextrose gel for Asymptomatic Hypoglycemia in Newborns

      Solaiman, Anjana; Wise, Barbara V. (2020-05)
      Problem & Purpose: Neonatal asymptomatic hypoglycemia is a common problem that may contribute to poor health outcomes. Firstline treatment includes formula feeding, and/or transfer to the Neonatal Intensive Care Unit (NICU) for intravenous glucose. Both of these treatment options are sub-optimal because breastfeeding/bonding are disrupted, and costs may be increased due to NICU care. The purpose of this quality improvement (QI) project was to implement 40% buccal dextrose gel as the first line treatment of asymptomatic hypoglycemia in newborns at an academic medical center in the mid-Atlantic region to improve glycemic outcomes. Methods: This QI project was implemented during a 12-week period in the Fall of 2019. The target population included infants admitted to the newborn nursery who were less than 24 hours of life (HOL) with an identified risk factor for hypoglycemia (birthweight >3800 grams or <2500 grams, gestational age <37 weeks, LGA or SGA, or is an infant of diabetic mother), with asymptomatic hypoglycemia (blood glucose levels between 20- 40mg/dl). The QI project involved modifying the hospitals current neonatal hypoglycemia clinical practice guideline (CPG), to implement 40% dextrose gel as initial therapy in conjunction with feeding, developing an order set, creating documentation in the electronic health record, training personnel and collaborating with pharmacy to stock the gel. Results and Conclusions: During the implementation 16 newborns received glucose gel (N=16). Treatment success, defined as blood glucose levels >40mg/dL following the first and/or second administration of gel, was achieved in 87.5% of newborns. Newborns who did not respond favorably to glucose gel had an initial blood glucose level of <20mg/dL, a deviation from the modified CPG. Fifty five percent of newborns who were exclusively breastfeeding (N=9) received medically indicated formula supplementation. Five patients were transferred (N=5) to the NICU, 2 patients had achieved treatment success, but were unable to maintain adequate glycemic levels. Future QI cycles should include exploration of treatment failure with modifications to improve CPG adherence, consideration for increasing doses for responsive newborns as well widening the gestational age criteria. Overall the outcomes of this QI project demonstrated that glucose gel as the initial treatment for infants with asymptomatic hypoglycemia is effective.
    • A Neonatal Dextrose Gel Algorithm to Increase Exclusive Breastfeeding Rates at Discharge

      Indenbaum-Bates, Keisha N.S.; Satyshur, Rosemarie D. (2022-05)
      Problem & Purpose: Over 80% of newborns nationally are breastfed after birth, yet the exclusive breastfeeding rate of a Women’s Health Services Department was 8%. Formula supplementation of hypoglycemic breastfed babies was identified as a contributing factor to this problem. Evidence demonstrates that using oral dextrose gel to treat neonatal hypoglycemia is safe, efficacious, and can increase breastfeeding rates. The purpose of this project was to implement an oral dextrose gel algorithm for the management of neonatal hypoglycemia to increase exclusive breastfeeding rates at discharge. Goals were to educate 100% of staff nurses on the practice change, administer the gel to 100% of eligible newborns, establish euglycemia in 100% of eligible newborns, and increase exclusive breastfeeding rates at discharge. Methods: A quality improvement project was designed to implement a neonatal dextrose gel algorithm over a 21-week period on a 26-bed mother-baby unit by a team of key stakeholders. In-services and hands-on validations were used to educate staff and the practice change was integrated into the electronic health record system and department policies prior to implementation. The implementation team met weekly to discuss progress and barriers, change champions were used to increase uptake, visual reminders of the algorithm were placed in key areas, and staff huddles were used for continuing education. Results: 95.8% of staff nurses were educated and validated on the practice change, average adherence to the algorithm was 47.2%, and the exclusive breastfeeding rate of newborns at risk for hypoglycemia increased from 17.7% to 18.7% (p=0.9). No babies became hypoglycemic during the implementation phase. Conclusions: Implementing a neonatal dextrose gel algorithm on a mother-baby unit is feasible and can help promote exclusive breastfeeding. Integration into formal unit policies and both new-hire and annual staff competencies is key to sustainability.
    • Standardized Dextrose Gel Policy Implementation for Management of Asymptomatic Neonatal Hypoglycemia

      Gertner, Alexandra; Fitzgerald, Jennifer (2021-05)
      Problem: Asymptomatic neonatal hypoglycemia in the first 48 hours of life is a frequent challenge faced by newborns. Timely management is crucial to minimize negative impacts. Data collected from the mother/baby unit of one community hospital demonstrated that despite introduction of oral dextrose gel in 2018, neonatal intensive care unit transfers and exclusive breastfeeding in neonates with asymptomatic hypoglycemia who received gel did not improve. Purpose: The purpose of the quality improvement (QI) project was to implement and evaluate the effectiveness of a standardized policy guiding the administration of oral 40% dextrose gel in at risk neonates ≥ 35 weeks’ gestation who presented with asymptomatic hypoglycemia within the newborn nursery at a community hospital in the United States. Methods: In collaboration with nursing and medical leadership, the project lead created an evidence-based policy, updated neonatal hypoglycemic algorithms to align with the policy, and developed standardized orders for the dosing and administration of oral glucose gel. Essential to project success was the development and implementation of a plan to improve nursing knowledge and compliance through PowerPoint presentations, simulated gel administration demonstrations, as well as dissemination of the updated algorithm on the unit. Data was obtained through weekly audits and tracking outcomes such as NICU transfers and exclusive breastfeeding rates. Results: Due to unforeseen delays, including the COVID-19 pandemic, project implementation occurred in two stages. All unit nurses (n=33) were educated on administration of oral glucose gel and the updated policy and algorithm by November 1, 2020. This measure alone resulted in decreased NICU transfer rates for infants with asymptomatic neonatal hypoglycemia. The second stage, policy/algorithm implementation, went live on December 21, 2020. All of the neonates who met the inclusion criteria (n=27) received intervention(s) consistent with the policy. Though NICU admission rates related to asymptomatic hypoglycemia remained low, exclusive breastfeeding rates did not increase. Conclusions: Future QI cycles should include further data collection to observe outcomes consistent with literature evidence. Potential implications include a focus on maternal breastfeeding preference within the electronic health record (EHR) to determine if exclusive breastfeeding rates in those mothers who wish to do so will improve.