CLINICAL GUIDELINE FOR THE CARE OF PEOPLE WITH DIABETES THE MANAGEMENT OF HYPOGLYCAEMIA IN ADULTS 1.

Aim/Purpose of this Guideline

This guideline is for the management of Hypoglycaemia in Adults with Diabetes. It has been benchmarked against national guidance, to provide detailed guidance on the clinical management of hypoglycaemia in line with best practice guidelines. This guideline applies to all healthcare professionals involved in the treatment of hypoglycaemia

2. The Guidance
Hypoglycaemia
Hypoglycaemia (which literally means low sugar in the blood) occurs when the blood glucose falls below 4 mmol/l

Symptoms of Hypoglycaemia
may include one or more of the following Sweating Hunger Pallor Headache Odd behaviour, confusion, aggression Weakness Drowsiness

All episodes of hypoglycaemia i.e. glucose < 4mmol/l should be treated even if symptoms are not present
References G. Williams, J Pickup 2009 :The Handbook of Diabetes 3rd Edition. The Oxford Centre for Diabetes, 2002 Endocrinology and Metabolism. Diabetes UK 2010 (Online) Resuscitation Council(UK) 2010 (Online) NHS Diabetes 2010 : The Hospital Management of Hypoglycaemia in Adults with Diabetes Mellitis

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Initial Management of Hypoglycaemia (For patients who are enterally fed whilst nil by mouth see page 3) Is the peripheral blood glucose < 4 mmol/l Yes If the peripheral blood glucose < 2.8 mmol/l a venous sample must be obtained as per policy Clinical guideline for use of Nova Stat Strip blood glucose meter (Do not wait for the result before treating the hypo) No Hypoglycaemia management is not appropriate. BUT consider other reasons for symptoms and review soon as blood glucose may be dropping rapidly

Is the patient conscious and able to swallow? Yes 1. Inform medical staff 2. Give 15 - 20 grams of fast acting carbohydrate 15-20 grams is 150-200 mls of pure fruit juice 90-120 mls of Lucozade original 150-200 mls of Coca Cola original 30-40 mls (to be diluted) of Ribena original 4 - 5 Glucotabs 3 - 4 heaped teaspoons of sugar dissolved in a non milky drink Or 3. If the patient is Nil By Mouth 1 - 2 tubes of Glucose oral gel squeezed into the side of the mouth. (not swallowed).Rubbing the cheek can aid absorption. 4. Repeat peripheral blood glucose in 10 minutes. N.B. follow this process twice only then seek medical review for Intravenous glucose / IM Glucagon No 1. Inform medical staff 2. Intravenous injection of 50 mls of 10% glucose (must be prescribed) 3. Further intravenous injection 50mls of 10% glucose every minute until the glucose is > 4 mmol/l (must be prescribed) (give up to 150 mls in total) Or 4. 1 mg of glucagon s.c, or i.m. (must be prescribed) * Then 5. Repeat peripheral blood glucose in 10 minutes. Glucagon may be ineffective in episodes of hypo precipitated by the ingestion of alcohol N.B. follow this process twice only then seek medical review

Is the peripheral blood glucose< 4mmol/l Yes No

If the patient is conscious and not nil by mouth 1. Follow up with long acting carbohydrate i.e. 2 plain biscuits or 1 slice of toast or 200-300 mls of milk (Double the amount if Glucagon used) Or 2. A meal with carbohydrate if the next meal is due. If the patient remains unconscious or is nil by mouth obtain medical review Guidance Notes Do not withhold insulin / medication. Once the hypoglycaemia has been treated as per the above guidelines, administer usual insulin / medication to prevent rebound hyperglycaemia. Intravenous Insulin Infusion is not a treatment for hypoglycaemia Note that hypo due to overdose of oral hypoglycaemics/insulin/ may be prolonged and may require prolonged dextrose infusion Continue regular blood glucose monitoring for at least 24 -48 hours. Long term management - medical review of insulin / medication / cause of repeated episodes of hypoglycaemia. For further advice refer to Diabetes In-Patient Specialist Nurse bleep 2205 / #3104 or the Endocrine team

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Initial Management of Hypoglycaemia Adult inpatients with Diabetes who are being ENTERALLY fed whilst nil by mouth
Is the peripheral blood glucose < 4 mmol/l Yes If the peripheral blood glucose < 2.8 mmol/l a venous sample must be obtained as per policy Clinical guideline for use of Nova Stat Strip blood glucose meter (Do not wait for the result before treating the hypo) No Hypoglycaemia management is not appropriate. BUT consider other reasons for symptoms and review soon as blood glucose may be dropping rapidly

1. Inform medical staff 2. Give 15 - 20 grams of fast acting carbohydrate via the enteral feeding tube (by gravity use a purple syringe as per NPSA). 15-20 grams is 45-60 mls Juice style Supplement Drink (ProvidExtra Juice Drink, Ensure Plus Juice or Fortijuice) 30-40 mls of Ribena original (do not dilute) 3-4 heaped teaspoons of sugar dissolved in sterile water Then flush with 50mls of sterile water

N.B. follow this process twice only then seek medical review for Intravenous glucose / IM Glucagon

Repeat peripheral blood glucose in 10 mins Is the peripheral blood glucose< 4mmol/l Yes No

1. Follow up with long acting carbohydrate via enteral feeding tube: Restart Enteral feed or give 100 mls of Milky Supplement drink (Fresubin Energy Drink, Ensure CC/BH Plus Milk Shake Style, Fortisip)

Guidance Notes
Do not use Oral Glucose Gel due to risk of aspiration Avoid using fizzy drinks or fruit juice as these can damage the tube Do not withhold insulin / medication. Once the hypoglycaemia has been treated as per the above guidelines, administer usual insulin / medication to prevent rebound hyperglycaemia. Continue regular blood glucose monitoring for at least 24 -48 hours. Long term management - medical review of insulin / medication / cause of repeated episodes of hypoglycaemia. Intravenous Insulin Infusion is not a treatment for hypoglycaemia Note that prolonged hypo may require prolonged dextrose infusion For further advice refer to Diabetes Dietitian bleep 2955 / #4569 / #2409

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3. Monitoring compliance and effectiveness

Element to be monitored Lead Tool Frequency Compliance Specialist Adult In-Patient Diabetes Team Patient Documentation Adult diabetes In-patients who are reviewed by the specialist diabetes team who have required management of Hypoglycaemia Reporting Non compliance will be reported to the ward /area manager. arrangements Repeated non compliance will be reported via Datix Acting on Ward / Area managers will undertake subsequent recommendations recommendations and action planning for any or all deficiencies and Lead(s) and recommendations within reasonable timeframes for their areas The Specialist Adult In-Patient Diabetes Team will undertake any trust wide recommendations and action planning for any or all deficiencies and recommendations within reasonable timeframes Change in practice and lessons to be shared Lesson learned or changes to practice will be shared with all the relevant stakeholders

4. Equality and Diversity

4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement.

4.2. Equality Impact Assessment

The Initial Equality Impact Assessment Screening Form is at Appendix 2.

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Appendix 1. Governance Information

Document Title Date Issued/Approved: Date Valid From: Date for Review: Directorate / Department responsible (author/owner): Contact details: Clinical Guideline For The Care Of People With Diabetes The Management Of Hypoglycaemia In Adults 19 Jul 12 19 Jul 12 1 July 2015 Amanda Veall Clinical Nurse Specialist Diabetes 01872 253104 Treatment for hypoglycaemia in adults with diabetes Diabetes RCHT Medical Director April 2012 Guidelines For The Management Of Hypoglycaemia In Adults Diabetes In-Patient Specialist Nurses, Specialist Diabetes Dietitian, Consultant Endocrinologists Rowena Green Not Required {Original Copy Signed} Internet & Intranet Intranet Only PCT CFT

Brief summary of contents

Suggested Keywords: Target Audience Executive Director responsible for Policy: Date revised: This document replaces (exact title of previous version): Approval route (names of committees)/consultation: Divisional Manager confirming approval processes Name and Post Title of additional signatories Signature of Executive Director giving approval Publication Location (refer to Policy on Policies Approvals and Ratification): Document Library Folder/Sub Folder Links to key external standards Related Documents:

Clinical/ Endocrine And Diabetes NSF Diabetes Standards 7 and 8 NHS Diabetes: The Hospital Management

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Training Need Identified?

of Hypoglycaemia in Adults with Diabetes Mellitus March 2010 Yes / Learning and Development have been informed via email 15/05/2012

Version Control Table Date March 2010 30 April 2012 Version No V1.0 Summary of Changes Initial Issue Amendment to quantities of CHO and enterally fed patients in accordance with national guideline Changes Made by (Name and Job Title) Amanda Veall Clinical Nurse Specialist Diabetes Amanda Veall Clinical Nurse Specialist Diabetes

V2.0

All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager.

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Appendix 2.Initial Equality Impact Assessment Screening Form

Name of service, strategy, policy or project (hereafter referred to as policy) to be assessed: Clinical Guideline For The Care Of People With Diabetes The Management Of Hypoglycaemia In Adults Directorate and service area: Diabetes Is this a new or existing Procedure? Existing Name of individual completing Telephone: 01872 253104 assessment: Amanda Veall 1. Policy Aim* To provide detailed guidance on the clinical management of hypoglycaemia in line with best practice guidelines. 2. Policy Objectives* To provide a consistent approach to the management of hypoglycaemia at RCHT sites. To maintain patient safety and improve outcomes for patients experiencing hypoglycaemia whilst inpatients at RCHT sites 3. Policy intended Consistent management of hypoglycaemia at RCHT Outcomes* sites. Prompt and safe management of hypoglycaemic episodes and follow up care. 4. How will you measure Audit the outcome? Datix Reporting Review of nursing/ medical documentation as required 5. Who is intended to All patients with diabetes who experience hypoglycaemia in benefit from the Policy? hospital at RCHT sites. 6a. Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? b. If yes, have these groups been consulted? Yes

Yes

c. Please list any groups Diabetes Inpatient Specialist Nurses who have been consulted Consultant Endocrinologists about this procedure. Diabetes Dietician

*Please see Glossary 7. The Impact Please complete the following table using ticks. You should refer to the EA guidance notes for areas of possible impact and also the Glossary if needed. Where you think that the policy could have a positive impact on any of the equality group(s) like promoting equality and equal opportunities or improving relations within equality groups, tick the Positive impact box. Where you think that the policy could have a negative impact on any of the equality group(s) i.e. it could disadvantage them, tick the Negative impact box.

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Where you think that the policy has no impact on any of the equality group(s) listed below i.e. it has no effect currently on equality groups, tick the No impact box. Positive Impact Negative Impact No Impact x x x x x x x x x Reasons for decision

Equality Group Age Disability Religion or belief Gender Transgender Pregnancy/ Maternity Race Sexual Orientation Marriage / Civil Partnership

You will need to continue to a full Equality Impact Assessment if the following have been highlighted: A negative impact and No consultation (this excludes any policies which have been identified as not requiring consultation). 8. If there is no evidence that the policy promotes equality, equal opportunities or improved relations - could it be adapted so that it does? How? Full statement of commitment to policy of equal opportunities is included in the policy

Please sign and date this form. Keep one copy and send a copy to Matron, Equality, Diversity and Human Rights, c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Chyvean House, Penventinnie Lane, Truro, Cornwall, TR1 3LJ A summary of the results will be published on the Trusts web site.
Signed ________Amanda Veall________________________________

Date _____10-07-2012____________________________________

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