Transcript Teamwork pays off with hypoglycemia protocol!

Evidenced Based Practice
Neonatal Hypoglycemia
Presented To
Department of Nursing
March 5, 2008
Carol Burke, APN
Teamwork pays off
with
hypoglycemia protocol!
Identification of babies at risk
 Assistance with feeding
 Compliance to protocol from 19% to 85%
Keep up the excellent work
Recognizing quality patient care and nursing excellence,
the ultimate benchmark patients can expect to receive
 admissions from 116 to 35 to NICU
related to hypoglycemia in 1 month!
•Moms and babies stay together
•Better glucose control for babies
Evidenced Based Practice
• A problem-solving approach utilizing
the current best evidence in making
decisions about patient care.
• Evaluate and revise current nursing
practice based on research and expert
opinion and standards of practice.
Glucose Stabilization
Hey, you could
have shared
some glucose
Continuous supply of maternal glucose via placenta
Mean glucose reading
IDM can be a very low
glucose reading
Glucose Stabilization after Birth
Reserves needed in immediate neonatal period when transfer of glucose is abruptly stopped
120
100
80
Glucose
value
60
40
Hours of age
6
5
4
3
2
1
0
h
> 55mg/dL
20
bi
rt
Normal newborn
Glucose at PWH is
Glucometer accuracy
75% of the time, the glucometer
overestimates
blood glucose
+10mg/dL
55
45
Neonates “at risk” for hypoglycemia
Too much
Too
much
insulin?
Too few reserves?
Too
few
Preterm
reserves
SGA, IUGR
insulin
IDM
& LGA
Too
much demand?
Too
much
Resuscitation,
Hypothermia
demand
Tachypnea
Sepsis
Can we do anything
to minimize the drop
in glucose?
Keeping baby warm and early feeding
will minimize the decrease in blood sugar
120
Original
glucose
value
100
Effect of
feeding
and
warmth
60
Glucose fall is
potentially decreased
80
40
20
bi
rt
6
5
4
3
2
1
h
0
Nursing practice priorities
immediately after birth
• NRP stabilization
• Keep baby warm – skin to skin
• Feed baby within 30-60 minutes
For ALL
babies
Glucose is primary fuel
for brain function
When to assess glucose?
A status check
on glucose
stability
120
100
80
60
40
Feed
first
20
Hours of age
6
5
4
3
2
1
h
0
bi
rt
Glucose
value
Schedule for
feeding and glucose measurement
 = feed BEFORE glucose check
Risk factor 30
1 hr
min
X = feed AFTER glucose check
3hr
6hr
9hr
12hr
15
18
21
24


X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
LGA

X
X
X
X
Discontinue if last 3
readings >55mg/dL
APGAR
<6

X
X
IDM
< 37 wks,
SGA
Symptomatic

Discontinue if last 3 readings > 55mg/dL
When symptoms present – follow #7 (Intervention Pathway)
If ANY glucometer reading is
55 or less
the infant just bought a ticket to the
Newborn on protocol
NICU
ANY Glucose check
<40mg/dL
Formula Feed
10ml/Kg
Significant Hypoglycemia
Newborn on protocol
NICU
Second glucose reading
After the feeding is
> 55
Second
Glucoseglucose
check
reading
40-49mg/dL
Is < 55 mg/dL
Wait 30 minutes,
then recheck glucose
Moderate Hypoglycemia
Formula Feed
10ml/Kg
Newborn on protocol
NICU
Glucose > 55
Wait 30 minutes,
then recheck glucose
Second
Glucose
Third reading
reading
check
50
remains
remains
- 55mg/dL
<< 55
55
Breastfeed or
Formula Feed
3rd reading
Wait 30 minutes,
then recheck glucose
Formula Feed
10ml/Kg
Cleanse site with
alcohol prep.
Wipe DRY with
sterile gauze pad.
Warm site with soft cloth,
moistened with warm water
up to 100, or use heel warmer
for 3-5 minutes
Puncture skin,
Hatched area
indicates safe
areas for puncture
site.
wipe off first drop
of blood with
sterile gauze
use second drop
of blood
Compliance with Hypoglycemia Protocol
New Hypoglycemia
Protocol
implemented
120
80%
70%
100
60%
80
50%
40%
60
30%
40
20%
20
10%
0
n0
Ju 6
lA 06
ug
-0
Se 6
p0
O 6
ct
N 06
ov
D 06
ec
-0
Ja 6
nF e 07
b0
M 7
ar
-0
A 7
pr
M 07
ay
Ju 07
n0
Ju 7
lA 07
ug
-0
Se 7
p0
O 7
ct
N 07
ov
D 07
ec
-0
Ja 7
n08
0%
Ju
Percent Compliance
90%
140
Compliance with Hypoglycemia Protocol
Total Cases
Privileged and Confidential Under the Illinois Medical Studies Act
Number of Hypoglycemia Cases
100%
Summary
•
•
•
•
•
•
•
Moms and babies stay together
Stabilized glucose control for babies
 Identification of babies at risk
 Assistance with feeding
 Compliance to protocol from 19% to 85%
 admissions to NICU
Incidence of hypoglycemia congruent with
expected volume