• 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.
    • Improving Provider Compliance with Glycemic Guidelines in Children with Type 1 Diabetes

      Burr, Mary S. (2016)
      The serum glycated hemoglobin or hemoglobin A1c (HbA1c) measurement is the most important long-term measurement of glycemic control and treatment effect when caring for the child with Type 1 diabetes mellitus (T1DM). The goal of treatment in diabetes is to maintain the patient’s blood glucose within a specific therapeutic range. A team of specialized providers is typically responsible for the care of these children, and continuity of the treatment among providers has been shown to improve glycemic control. Additionally, provision of guideline driven care has been shown to have positive outcomes in terms of therapeutic HbA1c measurement. In January 2015, The American Diabetes Association (ADA) released revised HbA1c guidelines for children with T1DM. Their recommendation was all children with T1DM should have an HbA1c level of < 7.5%. The goal of this quality improvement (QI) project was to promote and measure the level of provider compliance with current (2015) ADA glycemic guidelines using a standardized phrase for documentation in the electronic medical record (EMR). Methods: There were three phases to the implementation of the project. The initial phase was the completion of an EMR audit to assess the current HbA1c measurements of the pediatric patients in the clinic. The second phase was performance of a survey to assess provider knowledge of current ADA guidelines and the third phase was the creation and implementation of a “smart phrase” for EMR documentation, which confirmed that the HbA1c measurement and the recommendations of the ADA had been addressed with the patient and family. At the completion of the intervention phase, the project leader performed a manual retrospective chart review, which provided the nominal data needed to measure provider compliance in the use of the EMR smart phrase. Results: The project took place in a Diabetes and Endocrinology Center of a large urban academic medical center. The convenience sample of providers consisted of 9 pediatric diabetes care providers who currently practice at the center: three pediatric endocrinologists, three pediatric nurse practitioners and three certified diabetes educators. Data collection for the project was conducted over a six-week period, capturing 122 patient visits. Overall there was a 59% provider compliance rate with smart phrase usage; the group most compliant in smart phrase usage was the group of APRN providers, who used the phrase in 70% of patient visits. Conclusions: The standardized EMR phrase was helpful in identifying provider compliance with discussing current ADA guidelines when utilized. Consistent use of the smart phrase reflects guideline-driven care by diabetes providers and sends a clear message to families of patients with T1DM regarding the importance of glycemic control and improved patient outcomes.