Incidence of Severe Hypoglycemic Episodes

Definition
Control of glucose can reduce a patient’s risk for infections and mortality. However, the most common complication of aggressive glucose control is severe hypoglycemia, which can be life threatening. Careful measurement of the frequency of hypoglycemia allows clinicians to pace the aggressiveness of their control efforts as they develop a safe protocol.
 
Numerator: The total number of glucose values less than or equal to 40 mg per deciliter (2.2 mmol per liter).
 
Denominator: The total number of glucose values collected.
 
Measure calculation: Numerator/denominator * 100
 
Aim
Achieve glucose control less than 180 mg/dl in 100 percent of critically ill patients without increased incidence of severe hypoglycemia.

Goal
Less than or equal to 0.5 percent of all glucose values are in the severely hypoglycemic range (the rate of severe hypoglycemia in the NICE-SUGAR study [1]).

Data Collection Plan
Definition of Hypoglycemia:
Severe hypoglycemia as defined in the major trials on glucose control in critically ill patients has been defined as a value less than or equal to 40 mg per deciliter (2.2 mmol per liter).
 
There is also value in considering the lower limit of normal at your institution, which is typically 60 to 70 mg per deciliter. We suggest a separate measurement system to capture cases of relative hypoglycemia.
 
Frequency of Collection:
Ideally, data collection would occur daily with calculation of results monthly for the most accurate assessment of performance. However, in the absence of obtaining batched data from your information technology department or central laboratory on a regular basis, this is an ambitious collection effort.  For manual collection of data, the frequency of sample collection may be twice weekly or even once weekly. Trends become more difficult to interpret reliably as the interval between collection periods increases, however.
 
Point-of-Care Testing:
Special considerations come into play with regard to collecting data for glucose measurement. If you intend to rely on batched data from the central laboratory this may or may not include point-of-care finger stick glucose values. Since most glucose values collected from patients on an insulin drip tend to be point-of-care collections, an accurate tally should include these values.
 
 
Clinical Evidence
  1. NICE-SUGAR Study Investigators, Finfer S, Chittock DR, Su SY, et al. Intensive versus conventional glucose control in critically ill patients. New England Journal Medicine. 2009 Mar 26;360(13):1283-1297.
 

Sample Graph

graph_percenthypoglycemicepisodes.jpg
 

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