• Krista E Shea, Sally O Gerard, and James S Krinsley.
• Krista E. Shea is a critical care staff nurse, Stamford Hospital, Stamford, Connecticut. Sally O. Gerard is an inpatient diabetes educator, Stamford Hospital, and an associate professor of nursing, Fairfield University, Fairfield, Connecticut. James S. Krinsley is Director of Critical Care, Stamford Hospital, and Clinical Professor of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York.
• Crit Care Nurse. 2019 Aug 1; 39 (4): 29-38.

BackgroundSuccessful blood glucose control is associated with improved outcomes of critically ill patients. However, insulin treatment can cause hypoglycemia, an important patient safety concern. The Joint Commission has recommended that all episodes of hypoglycemia be evaluated with a root cause analysis.ObjectiveTo reduce episodes of hypoglycemia through the analysis of data related to each episode.MethodsThe interdisciplinary team of the 16-bed critical care unit of a university-affilited teaching hospital developed a process to analyze, in real time, each episode of hypoglycemia (blood glucose level <60 mg/dL), including evaluation of patient risk factors and nursing interventions. The nursing staff integrated the root cause analysis into daily practice. The preimplementation period encompassed 2429 consecutive admissions, and the implementation period encompassed 2608 consecutive admissions.ResultsThe percentage of patients with hypoglycemia decreased substantially during the implementation period among those without (from 6.15% to 3.78%; P = .001) and with diabetes (from 13.14% to 7.23%; P = .002). Mean blood glucose level decreased during the implementation period among patients without diabetes (P < .001), and did not change significantly among patients with diabetes (P = .23). The coefficient of variation, reflecting glucose variability, decreased during the implementation period among patients without and with diabetes (P < .001 for each).ConclusionThe nurse-driven root cause analysis was associated with a substantial reduction in hypoglycemia, with concomitant decreases in mean blood glucose level among patients without diabetes and glucose variability in patients without and with diabetes.©2019 American Association of Critical-Care Nurses.

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