Managing Hypoglycaemia in Diabetic Patients

1. Introduction

Hypoglycaemia is a Diabetes Mellitus complication that often comes about and causes harmful effects for diabetes patients. Yale, Paty and Senior (2018), define hypoglycaemia as a condition where levels of blood glucose reach 70 mg/dL. Whenever this happens, a counter-regulatory mechanism is kick-started and different people have different thresholds. Among patients with type 1 diabetes, the prevalence of severe hypoglycaemia is 0.2 – 3.2 episodes per annum per patient, while among patients with type 2 diabetes the prevalence is 0.1 – 0.7 (Silbert et al. 2018). It is often not easy to recognise mild hypoglycaemia and this is mainly because patients with diabetes never realise nor remember the hypoglycaemic events, and that is especially in those scenarios where there have been more than one experience of hypoglycaemia every other weak. Hypoglycaemia can be classified as either primary or secondary hypoglycaemia (Shah et al. 2020). Primary hypoglycaemia is when the hypoglycaemia was the primary cause of being admitted to hospital, while secondary hypoglycaemia is when the hypoglycaemia comes about during a patient’s hospitalisation (in-patient hypoglycaemia). The focus of this paper is on secondary hypoglycaemia, that is, in-patient hypoglycaemia. Singh et al. (2020), point out that there are several risk factors that bring about in-patient hypoglycaemia and these include; comorbid diseases, diabetes types, previous hypoglycaemia history, aggressive hyperglycaemia therapy, inadequate monitoring of glucose, physician instructions that are either unclear or unreadable, limited facilities, prolonged fasting, incompatible nutritional intake and advanced age, among others. In diabetes, hypoglycaemia is a condition that occurs when the blood glucose levels fall low enough to cause signs and symptoms. Also, hypoglycaemia brings about different problems within the human nervous system. Some of the earliest symptoms are dizziness, lightheadedness and weakness. There is also the possibility of headaches occurring and that is especially if a patient suffers from diabetes. A patient could also feel the signs of stress including irritability, anxiety, and nervousness. Evidence shows that the experiences of hypoglycaemia among patients with diabetes have a negative effect on the patient’s interpersonal relationships and how they view themselves (Brown et al. 2019). In addition, hypoglycameia is described as a quite private experience that patients rarely discuss with other people (Kenny, 2014). About 25-30% of all patients on insulin suffer one or more episodes of severe hypoglycaemia. However, the risk of mild to severe hypoglycaemia increases steadily as glycaemic control improves (Pratiwi et al 2020). In 2016, the National Diabetes Inpatient Audit estimated that 17% of hospital inpatients have diabetes, Diabetes has been shown to negatively impact both mortality and length of hospital stay in a variety of medical and surgical settings. In the UK, 23% of inpatients with diabetes experience hypoglycaemia while admitted. In Scotland, 16% of all hospital episodes where CBG was reviewed found at least one patient with hypoglycaemia. Regular blood glucose assessment, rapid identification and facilitating timely targeted care is, therefore, vital.

Within hospital settings, nurses lead the detection and treatment of hypoglycemia and are assisted by auxiliary healthcare professionals in the measurement of glucose, where their input is only sought in increasingly severe, which requires further management (Rana et al. 2021). Often, hospital pharmacy staff also play a pivotal role in the daily management of inpatients, detection and enacting need for therapy modality and changes in doses, triggering medical review of management, and providing advice on alternative strategies. The researcher works as a diabetes specialist nurse in the same trust, a borough that has the highest patient with diabetes needs. As an insider researcher, I have observed the need for both staff and patient to receive a good standard of care that support and identify areas to improve in the care delivered. A study conducted a qualitative review on risk factors for inpatient hypoglycemia. The results of this review were presented in a comprehensive report.

2. Aims and Objective

This study was aimed at determining whether inpatient hypoglycemic episodes were treated in line with the set protocols, investigate the presence of modifiable risk factors for hypoglycemia and additionally identify whether these were addressed in accordance with specialist evidence. Deciding on this topic is, in part, based on the researcher’s experience as a diabetes specialist nurse. As a specialist nurse the researcher witnesses the lack of risk management and pro-active interventions, offered by ward nurses. It is recognised in the literature that hypoglycaemia in hospitalised diabetic patients is common and that reoccurring hypoglycaemic attacks can have a serious and long-term effect on the general health status of the patient (Stefanova, 2015). It therefore follows that to raise awareness of the need for a risk assessment and preventative interventions will benefit the care given to the person with diabetes and, while not the aim of this research, will lead to an improvement in patient outcomes.

In order to assist this aim, the researcher has made three distinct objectives;

To establish what intervention are used by the nursing staff in the inpatient setting to safely manage or avoid hypoglycaemia.

To understand to what extent nurses do follow protocols to avoid and manage hypoglycaemia.

To recognise the training needs of nurses in the department in the management of hypoglycaemia.

Guiding Literature

Hypoglycemia during hospitalization may be further divided into two categories: spontaneous and iatrogenic (Sinha Gregory et al., 2018). Hypoglycemia can occur in diabetic patients who have multiple organ failure, malnutrition, and a history of drug use, whereas iatrogenic hypoglycemia can occur as a result of excessively aggressive treatment of hyperglycemia, accompanied by the body's inability to respond to a decrease in blood glucose levels, which is referred to as “HAAF (hyperglycemia-associated acute a (hypoglycemia-associated autonomic failure)” (Silbert et al., 2018). Individuals with type 1 diabetes, those with severe comorbid diseases, the elderly, and those with a history of recurrent hypoglycemia are at risk for developing HAAF (Sinha Gregory et al., 2018). Type 1 diabetes is characterized by total disruption of cell function, which results in no regulation of insulin secretion and increased glucagon production under hypoglycemic conditions. Individuals with a history of recurrent hypoglycemia will experience a decrease in blood glucose levels, which will activate the counter-regulatory system, enabling hypoglycemia to become more severe and unnoticed (Silbert et al., 2018). In this illness, there is a 25-fold increased chance of developing severe hypoglycemia (Pratiwi et al., 2020). It is possible to reverse unidentified hypoglycemia if it is avoided for two–three weeks after it has been detected. Patients with HAAF will have a reduced catecholamine hormone response during hypoglycemia, which will essentially mitigate the effect of catecholamine cardiotoxicity. However, the ACCORD and ADVANCE studies (Action in Diabetes and Vascular Disease) discovered that strict blood glucose control, which will result in recurrent episodes of hypoglycemia that will result in HAAF, will have a negative effect on catecholamine cardiotoxicity in the long term.

The risk factors of inpatient hypoglycemia

It is possible that an increase in the incidence of hypoglycemia during hospitalization may be ascribed to a variety of risk factors such as individual, managerial, and institutional variables. The researchers discovered that age, severe comorbid diseases (such as sepsis, impaired renal function, malignancy, hypoalbuminemia, anemia, liver failure, and heart failure), other endocrine disorders such as adrenal insufficiency, growth hormone deficiency, hyper- or hypothyroidism, type and duration of diabetes, pregnancy, and low bovine serum albumin were all individually associated with the development of inpatient hypoglycemia (Sinha Gregory et al., 2018; Pratiwi et al., 2020). Extremely aggressive hyperglycemia therapy, changes in patient dietary intake, and prolonged fasting can all result in acute hypoglycemia, while institutional factors such as insufficient blood glucose monitoring, discrepancies between dietary intake and hyperglycemia therapy, unreadable or unclear medical instructions, and a lack of coordination and communication can all result in acute hypoglycemia. Patients suffering from renal disease are more prone to have hypoglycemia episodes. A decrease in gluconeogenesis, with 40% of it happening in the kidney, decreased insulin breakdown in peripheral tissues, decreased insulin clearance through the kidneys, anorexia, and autonomic neuropathy all contribute to an increase in its incidence (Pratiwi et al., 2020). Controlling blood glucose levels in diabetic individuals with end-stage renal failure is especially difficult because of metabolic acidosis and uremia, which both enhance insulin resistance and decrease insulin breakdown in patients who have just completed dialysis. It is also possible for diabetics with poor liver function to suffer hypoglycemia (Silbert et al., 2018). Gluconeogenesis and glycogenosis are two processes in which the liver is engaged in the metabolism of carbohydrates. In the long run, impaired liver function raises the likelihood of developing hypoglycemia. It is generally agreed that patients under the age of five and those over the age of sixty-five are the most vulnerable to hypoglycemia owing to their reduced ability to identify the signs and symptoms of hypoglycemia as well as their incapacity to communicate their needs (Silbert et al., 2018). Additionally, in older people, there is a decrease in the counter-regulatory hormonal response as well as a loss of autonomic nerve responses when they are hypoglycemic.

When oral anti-diabetic medications were used, hypoglycemia was also seen. When sulfonylureas were taken, hypoglycemia was seen more often. As reported by the “United Kingdom Prospective Diabetes Study (UKPDS)”, when glibenclamide was initially introduced, the incidence of moderate hypoglycemia reached 31% (Pratiwi et al., 2020). It has been shown that the incidence of hypoglycemia is lower in third generation sulfonylureas (glimepiride, glipizide, and glicazide) than in glibenclamide when compared to glibenclamide. This may be due to the fact that the medications have different half-lives, as well as to other confounding factors such as the fact that they have different effects on insulin sensitivity. Insulin treatment has long been linked with a higher risk of hypoglycemia in diabetic patients, according to research. Individuals who have been on insulin for more than 5 years are reported to have hypoglycemia at a rate of 25 percent (Pratiwi et al., 2020). According to the Indonesian Diabetes Association, 100 percent of type 1 diabetic patients who used insulin had at least one episode of hypoglycemia, whereas 99.4 percent of type 2 diabetic patients who used insulin experienced at least one episode (Pratiwi et al., 2020). In a prospective cohort study including 200 patients, Pratiwi et al (2020) found that 24 percent of patients had hypoglycemia after receiving continuous intravenous insulin therapy, with the frequency being greater in patients with type 1 diabetes. Insulin therapy, especially for diabetes patients who are hospitalized, must be accompanied with careful blood glucose monitoring to be effective.

3. Methodology

Introduction

Research methodology is the precise process that is used to locate, select, process, and evaluate data on topic of interest. This part of a research project mainly provides the opportunity to critically assess the overall validity of the study. The methodology section provides answers to the questions regarding the methods used to gather or produce the data along with the methods used to analyse. There are two main techniques and/or designs used to gather data. These techniques include quantitative research designs that use surveys to collect quantifiable data. However, qualitative research design is often used in research. This approach relies heavily on detailed information gathered through interviews. Specifically, the research utilizes questionnaires for the collection of data. It is worth noting that it is possible to classify questionnaires as either qualitative or quantitative and this is entirely dependent on the nature of asked questions. The use of questionnaires enables the collection of detailed individual perspectives and descriptions of processes, consequently ensuring that researchers develop an increasingly comprehensive understanding of the phenomenon of interest. Qualitative research has the benefit of attempting to explore and understand the perspectives of participants, as well as the importance of their lived experiences. Furthermore, it is flexible, and data collection is usually cost-effective; hence, this methodology was used for the present study.

Research Strategies

Many types of strategies are often used while doing research including quantitative and qualitative research. Quantitative research methods are defined by numerical or statistical analysis of data collected through questionnaires, and surveys while the qualitative research is the process of collecting and analysing non-numerical data (e.g., text, video, or audio) in order to get a deeper understanding of participants' ideas, perspectives, or personal experiences (Sim et al., 2018). It is employed to get in-depth knowledge about a subject. Since the present study aimed to get in-depth knowledge regarding the risk factors to reduce inpatient hypoglycaemia in the patient with diabetes, thus it employed qualitative research. The method's benefits include raising the department's knowledge of nurse management techniques and their degree of competence in treating diabetic patients at risk of hypoglycaemia. Patient care is anticipated to improve, as is team understanding of current care provision and prospective changes.

Data Collection Method

Ruggiano and Perry (2019) identified two types of data collection methods: primary and secondary. Primary methods include unprocessed raw data that can be collected through surveys, questionnaires, in-depth interviews, and observations. Secondary data refers to previously collected information that has been incorporated in other academics' research publications. Since there is limited data available on modifiable risk factors to reduce inpatient hypoglycaemia in the patient with diabetes, this study employed primary method for the data collection in order to get first hand data. A questionnaire was used to gather data since it is a cost-effective and time-efficient technique for assessing the behaviour, attitudes, preferences, views, and intentions of a large number of people. It is a straightforward method of developing, producing, and using data and requires no technological expertise or experience, and it removes the need for responders to reply immediately to a request for information. They may respond to questions at their convenience. Given the long work hours and hectic schedules of the potential participants, it was more convenient for them to complete a paper questionnaire during their spare time (break time), rather than an interview or observation, which need certain time and situation fixation. As a work-based project, the researcher's approach was as an insider-researcher, which had both positive and negative influences for completing the project. However, as an insider researcher was very mindful of any bias when my personal values and experiences does not influence the research questions, however, to take steps to minimize this potential bias through the different stages of the research process. (Chavez, 2008). It is argued that as an inside researcher you have a passion for the project you have been working on which means you would commit fully despite any challenges. When it comes to data validity, the questionnaire offers many advantages. The investigator's record of responses acquired via techniques such as interview and observation establishes the dependability of the responses. On the other hand, answers to the questionnaire method are accessible in the participants' native language and version. As a result, the results are not misconstrued. Additionally, it protects the privacy of those who participate in the study. Respondents have a higher chance of not being recognised as having expressed a specific opinion or point of view. This method envelops them in comfort and allows them to express freely.

Data Analysis

The developed questionnaires had all qualitative questions and therefore, the researcher resolved to analyze the data through thematic analysis. Thematic analysis is a process through which data is examined so that the perspectives of participants are meaningfully comprehended (Terry, Hayfield and Clarke, 2017). Through thematic analysis, recurrent patterns in data are identified and this puts the researcher in a better place to develop a detailed understanding of the collected data. Thematic analysis is a rather useful method for analysis of qualitative data and that is because it identifies patterns from the way participants communicate (Maguire and Delahunt, 2017). Therefore, the method of analysis is a valuable method for examination of the content of responses from the data that was collected from the questionnaires. The rationale for thematic analysis is the identification of patterns of meaning across data sets that provide answers to the research questions that are set to be addressed (Vaismoradi and Snelgrove, 2019). There is a rigorous process of data familiarization, data coding, theme development and revision that is followed for the identification but of patterns. The themes obtained through this analysis are anticipated to inform future recommendations for improved patient care and nurse training in hypoglycaemia treatment.

Sample Method and Size

The research took place on a diabetic ward. Registered nurses who deal closely with diabetic patients met the inclusion criteria. The sample size was six, and the research included individuals of both sexes and of no particular ethnic origin. A poster promoting the research was displayed in the department's staff room. The PICS and accompanying questionnaire were placed in the staff room, along with instructions to place the completed questionnaire in a sealed envelope to a designated box. Before completing the questionnaire, participants were requested to read the PICS in its entirety. Each participant completed a single questionnaire. The study's procedures were explained to the participants at a team meeting.

Ethical Consideration

Many people fear that their personal data may be released to the public, therefore it is suggested that responders and/or participants be made aware of the ethical norms and concerns. As a result, maintaining respondents' identity during the study is essential. The participants of the study picked up a Participant Information Consent Sheet Form (PICS) and Questionnaires from the designated place and no personal information was collected to identify any participant. The researcher ensured that only those individuals who consented to participating in the study were involved. Informed consent is one of the founding principles of research ethics. The intention of informed consent is that human researchers are in a position to freely, that is, voluntarily enter research and be provided with information on what taking part means, and that they consent to their involvement in the research (Hardicre, 2014). The study maintained participant anonymity by not revealing any of the participants' identities to other parties and keeping all data on a password-protected and secure Microsoft OneDrive. Permission from the department's management was also taken to conduct the study. After receiving permission from management, the team meeting was held to educate workers about the research, including its purpose and potential benefits to both the team and the patients. Permission was received in writing from the department head to perform this study and the University REC committee also granted their approval for the study to commence.

4. Project activity and leadership strategies

The chosen leadership style for reducing inpatient hypoglycaemia is democratic style. The democratic leadership style best describes my style of leadership. In managing the project activities the researcher made sure that the decisions are made with the input of the team in mind when a democratic leadership style is used. It is critical for this kind of leader that their workers feel secure and free to express their problems, views, and recommendations without fear of reprisal. The individuals must remember that a democratic leader believes in the need of giving constructive criticism to the members of his or her team. Nurses may benefit from democratic leadership if they feel appreciated and confident in their ability to express themselves especially in reducing inpatient hypoglycaemia (Ruan, et al., 2020). When it comes to high dependability organisations, transparency and feedback from team members with the most expertise, rather than those with the most seniority or the highest position, are stressed. As a result, this type of leader is useful in creating a culture that encourages input from the entire team especially for managing the project activities related to reducing inpatient hypoglycaemia. When a team is needed to respond quickly, this kind of leadership may be harmful to the team's performance. As a result, democratic leaders who are unable to make fast choices on their own and without feedback from their team may find it difficult to flourish in an atmosphere where unfavorable occurrences and crises take place. Therefore, the democratic style of leadership within the hospital domain should be used appropriately so that the goal of reducing inpatient hypoglycaemia should be achieved. Other than this the study conducted Singh, et al., (2020) also states that democratic leaders encourage staff nurses to discuss and participate in decision-making in an open and honest manner which will help the health professionals to solve the issues within the healthcare organization. Along with this, the democratic leadership will also reducing inpatient hypoglycaemia because it includes direct effective communication with the healthcare staff and with the patients directly. In order to increase work satisfaction and staff growth, a democratic leader focuses on developing connections with others. In democratic leadership, the goal is to improve systems and procedures rather than to point the finger at individual team members for errors. It promotes the formation of consensus. The decision-making process, on the other hand, is more time-consuming under democratic leadership, owing to the greater involvement of all team members. The involvement may cause anxiety among nurses with less expertise, while enabling more experienced nurses to have a disproportionate amount of influence in decision-making in certain instances.

5. Analysis and Findings

In this section of the paper, a thematic analysis was used in the views of participants who gave their respective views on the main topic of concern.

Fear of hypoglycaemia

The comments of four of the respondents indicate that hypoglycemia is a source of worry for diabetic patients in hospitals, as well as the Health care professionals which is consistent with their opinions. “I have observed that the fear of hypoglycameia among patients leads them to taking insulin which is done to ensure that their blood sugar levels don’t go too low. This holds the potential of contributing to uncontrolled diabetes.” R2 “In fear of hypoglycemia, patients reduce their physical activity. The fear actually worsens their control of blood glucose and less exercise.” R6 These respondents agree with Griesdale et al. (2009) in that critical illness, medication changes (such as rapid steroid decrease), emesis, reduced oral intake, fasting for operations, altered mental state due to anaesthesia or illness, and interruptions of glucose infusion, enteral, and parenteral nutrition are all factors that contribute to mortality (American Diabetes Association, 2013). Many people think that the most essential aspect is to match the timing and amount of such medicines, particularly insulin, to the time and size of meals. This is supported by research. Although diabetes specialists are aware of the necessity for this, other clinical and catering personnel may not be aware of its significance, according to the American Diabetes Association. On the other hand, the responses presented by the participants in the questionnaire are segmented into several themes, which are presented below.

Prevention of hyperglycemia

There was only suboptimal acute management of in-hospital hypoglycemia as evidenced by the questionnaire responses. There were multiple opportunities that were identified in the questionnaire responses as suitable interventions for reduction of the recurrence of inpatient hypoglycemia. These were the responses of registered nurses, individuals considered as being knowledgeable on the topic. One of the identified mechanisms for providing optimum care for patients with diabetes was balancing glycemic control through the prevention of hypoglycemia and hyperglycemia. All the respondents identified this as an essential mechanism. “Patients should never be complacent but should work on continuously maintaining proper glycemic control which is achievable by adhering to medications, continuously exercising, dietary controls, and regular monitoring and review, for purposes of maintaining euglycemic glucose levels.” R1 Inpatient teams are always possible to prevent and even reduce hypoglycemic events through the recognition of precipitating factors and triggering events, making orders for appropriate scheduled anti-diabetic oral agents or insulin, bedside monitoring of bedside glucose, offering education to family, friends, patients, and staff on the recognition of symptoms and offering appropriate treatment, provision of appropriate nutritional requirements, and application of systems for elimination and reduction of medication and treatment errors among in-patients. Recognition of precipitating factors was identified as another mechanism (Singh et al. 2020). Precipitating factors include errors in administered dosages, presence of a comorbidity for instance pituitary, renal and adrenal insufficiency, whose effects include heightening hypoglycemia risk. Inpatient staff are at a position to prevent hypoglycemic events through the conveyance of instructions that are appropriate in relation to the timing of meals, and administration of medication, heightening awareness of different medical conditions that have an influence on glucose control, and also encouraging patient self-care whenever possible. A possible means of reducing hypoglycemia is through self-management by patients whose diabetes is well controlled as outpatients and who have the capabilities to manage their insulin regimen when hospitalized, including those who use multiple daily injections of glargine and lispro and those who wear insulin pumps (Battelino et al. 2017). Across inpatient care, there was a significant number of hypoglycemic episodes that were not treated in line with the established protocol. Three of the respondents made statements pointing to the failure to do treatments in line with set protocols. “For a fact, our hospital has a well-established protocol for treatment of hypoglycemia. The primary and secondary prevention strategies are focused on mitigation of the effects of hypoglycemia. However, most of my colleagues and even I, do not always follow these protocols and do things in our own ways.” That has the potential of significantly bringing about harm to patients. Formalization of the role and presence of inpatient diabetes specialist outreach services for purposes of increasing expert advice would be a worthy change to current practice. Giving teams specialist advice verbally, carries the risk of the advice not being recorded or not being subsequently taken, limiting or preventing potential improvements entirely (Lucidi et al. 2018). Written advice on the case notes as formal recommendations could be actioned more oftently. For purposes of substantiating this, it could be necessary to carry out an increasingly rigorous process of follow-up reviews carried out by specialist teams, which could be done through the duration of admissions, facilitating improved outcomes. Balancing glycemic control was recognized by all the respondents as the most effective mechanism in providing patients with optimum care. This is characterized by continuous control of glucose levels and without any sorts of holidays, and is an essential tool for the prevention of the potentially serious consequences that could come about as a result of either very low or very high levels of blood glucose.

Overnight hypoglycemia

From the personal testimonies of the questionnaire participants, it is apparent that the majority of hypoglycemic episodes occur at night. “Throughout my many years of practice, I have observed that more than half of the episodes of low blood glucose, and the majority of the severe hypoglycaemia episodes happen at night when patients are asleep.” R3 “There are more cases of hypoglycemia at night and these come about as a result of daytime physical activity which effectively increases the sensitivity to insulin. Missing dinner and night time snacks are other common causes of the many cases of hypoglycaemia at night.” R5 The fourth respondent infers that a significant number of patients would benefit from increased overnight CBG monitoring when considering the number of instances of low glucose that were discovered in the morning. In addition to increasing the frequency with which high-risk individuals have their nightly CBG tests done, raising public awareness of this illness may also help in lowering the burden of hypoglycemia in the general population (Jones et al., 2014). In an unusual occurrence, a significant proportion of hypoglycemic episodes that occurred during inpatient treatment were not treated according to standard practise as a result. The repercussions for the individual who is experiencing it have the potential to be very devastating. It may be helpful to make positive changes to current practise, such as formalising the function and presence of inpatient diabetes specialist outreach programmes, in order to enhance access to expert advice (Rajendran et al., 2015:Torjesen, 2012). Whenever expert advise is given orally, team members seem to be less likely than other team members to record or follow up on it, thus limiting or entirely preventing potential advancements. Case notes with formal recommendations may be followed up on more often in the future than they have been in the past. To explain this, it is possible that a more rigorous method of follow-up assessments by expert teams during the admissions process would be required, ensuring consistency and better outcomes across the whole process.

Training

From the questionnaire results, it is also evident that the training and availability of specialist diabetes nurse practitioners is very valued. That owes to the empowerment and autonomy of delivery patients who work with clinicians and reduction of errors in prescribing, and the length of stay. Increasing the number of hospital beds is important. Diabetic nurse prescribers who are experts in the field have demonstrated that patient empowerment and autonomy through shared decision-making, self-care education, collaboration with physicians, and minimising prescription errors and resulting length of stay are all highly valued by diabetic nurse prescribers who are specialists in the field (Phillips & Wilkinson, 2015). Extended length of stay is mentioned as a major issue by 5 of the questionnaire respondents. The second respondent points out that extended length of stay is mainly a result of slow reaction time to cases of hypoglycemia, especially, the severe cases. “Most of the healthcare workers do not seem to be adequately experienced in dealing with cases of severe hypoglycemia, and are hesitant to take up the care of patients with hypoglycemia.” R2 Changing the function of diabetes expert teams from a consultative to a proactive one may ensure that necessary interventions are carried out; nevertheless, this would have significant resource implications and may result in hospital ward staff being less competent as a result of this change. Perhaps expanding the participation of hospital healthcare workers in diabetes care can assist to alleviate the issue of inadequate inpatient diabetes treatment (Smith, 2007). More contact with specialised services, ward education on hypoglycemia, regular CBG testing (along with other medications), and ensuring that appropriate treatment adjustments are done when iatrogenic hypoglycemia develops may all help to show greater levels of staff involvement. A stronger support and training programme for hospital staff in terms of ward outreach and teaching are required before it can be determined if a larger role for hospital staff will help reduce the burden of in-patient hypoglycemia. Diabetes patients are at risk for hypoglycemia, which nurses, physicians, and other health-care workers must be aware of in order to diagnose, treat, and most importantly prevent the condition. Systems and procedures for diabetes treatment help the health-care team in attaining glycemic goals for healing and health promotion while also ensuring a safe environment for those living with the illness.

6. Implications for findings

Diabetes patients are more likely than the general population to suffer from hypoglycemia (low blood sugar), according to scientific data. Hypoglycemic episodes in diabetic patients are often overlooked or forgotten, particularly if they have occurred on a regular basis for more than a week. As a result, moderate hypoglycemia is difficult to detect in diabetic patients. The distinctions between hypoglycemia and diabetes have been broadened to encompass both primary and secondary hypoglycemia, as well as diabetes. There are two classifications: main and secondary. Primary means that it was the primary reason for the patient's hospitalisation, and secondary means that it happened while the patient was in the hospital (inpatient hypoglycaemia). Diabetes type 1 patients, those with severe concomitant illnesses, the elderly, and anybody with a history of recurrent hypoglycemia are all at risk for developing hypoglycemia-associated acute flaccid paralysis (HAAF). During periods of hypoglycemia, type 1 diabetes is characterised by a complete breakdown of cell activity, resulting in a loss of control over insulin secretion and an excess of glucagon production. A drop in blood glucose levels in those who have had recurrent hypoglycemia will cause the counter-regulatory system to activate, allowing the hypoglycemia to worsen and go undetected. There is a 25-fold increase in the risk of severe hypoglycemia during this disease. Unexplained hypoglycemia may be reversed if it is avoided for two–three weeks after it has been diagnosed. HAAF patients will have a decreased catecholamine hormone response when hypoglycemic, which will lower their chance of developing catecholamine cardiotoxicity. According to the findings of the ACCORD and ADVANCE investigations, strict blood glucose management, which leads in repeated bouts of hypoglycemia and HAAF, has a long-term detrimental impact on catecholamine cardiotoxicity in the form of heart failure. ACCORD and ADVANCE are two major randomised controlled studies that are now underway (Action in Diabetes and Vascular Disease). On the other side, the gathered data through questionnaire also offered key insights related to the shreds of evidence collected in the literature. Hypoglycemia is a significant problem for diabetic patients in hospitals, and it must be dealt with immediately. Esophagitis, decreased oral intake due to surgery, changed mental state due to anaesthesia or illness, and pauses in glucose administration (including enteral nutrition) and parenteral nutrition are all variables that contribute to the development of this disease (American Diabetes Association, 2013). I believe that one of the most important was to coordinate meal time and quantity with the schedule and dosage of such medications, especially insulin. Others in the healthcare and catering industries, however, may not be aware of this, despite the fact that diabetes specialists are well aware of its significance. The hospital's reaction time to severe hypoglycemia was appallingly slow, according to the report. There were many intervention strategies available to decrease the risk of inpatient hypoglycemia; but the recommendations were seldom followed through on by the healthcare professionals who provided them. It is suggested that therapeutic changes be implemented as soon as possible rather than waiting for the expert team's recommendations to be made, due to the possibility that remote CBG testing may result in proactive professional guidance. It would be helpful to perform a follow-up research study to establish if patients who got and followed post-episode counselling had a reduced risk of recurrent hypoglycemia than those who did not get and follow post-episode counselling. Throughout a significant proportion of hypoglycemic episodes, hypoglycemia develops during the night. In this research, we found that many bouts of hypoglycemia occurred in the morning, suggesting that many patients may benefit from increased overnight CBG monitoring. It is possible that raising public knowledge of this, as well as increasing the frequency of nocturnal CBG testing in high-risk individuals, may help to decrease the burden of hypoglycemia in the future. In a significant percentage of cases, hypoglycemia episodes in hospitalised patients were not appropriately addressed. There is a high likelihood that this will be very dangerous for the sufferer.

In order to enhance access to expert advice within the current system, formalising the goal and presence of inpatient diabetes specialist outreach programmes may be a good idea. When specialists offer teams with oral advice, it seems that it is seldom documented or followed up on, limiting or entirely preventing the possibility of further advancement. It is likely that formal case note recommendations may be followed up on more often in the future. To be clear, a more rigorous method including follow-up assessments by expert teams throughout the admissions process may be required in order to guarantee consistency and better outcomes. Insulin patients had a lower percentage of concordance than patients treated with other diabetes treatment modalities, indicating that all patient groups, particularly those on insulin, need greater education on the importance of hypoglycemia monitoring and management, the researchers concluded. According to the findings, nurse prescribers who specialise in diabetes care are highly valued for empowering patients via shared decision-making and self-care education, working together with physicians, and decreasing prescription mistakes and hospitalisation length of stay. If diabetes expert teams moved from a consultative to a proactive position, they may be able to guarantee that essential interventions are carried out; nevertheless, this would have significant consequences for resource allocation and might de-skill hospital ward personnel. Separate investigations on people suffering from severe and non-severe hypoglycemia may provide insight on what is going on in this situation. Patient morbidity and mortality are affected in two distinct ways in these two situations, respectively. As a result, the treatment's urgency, expert guidance, physician or pharmacist requirements, and the possibility of recurrence should all be taken into consideration. In order to analyse hypoglycemia treatment disparities and evaluate the effectiveness of customised outreach and follow-up strategies, more study is needed. Establishing a high-quality diabetes treatment programme in the hospital, with a focus on properly treating and preventing hypoglycemia episodes, has the potential to reduce morbidity and mortality in the diabetic population. This study demonstrated how common hypoglycemia is in hospitals and how badly the vast majority of patients are handled. Hypoglycemia may be induced by a number of factors, many of which are therapeutically relevant in certain cases. Patient education programmes for diabetics, on the other hand, may not always be followed by their patients. The ability to play a larger role in the treatment of these patients, as well as the possibility of making their lives simpler, is made possible as a result. In order to establish whether or whether this approach may help to reduce the burden of inpatient hypoglycemia, more study should be carried out. It is possible that increasing the involvement of hospital pharmacists in diabetes care would help to solve the problem of insufficient inpatient diabetes treatment. It is possible to demonstrate higher levels of pharmacy staff engagement by increasing communication with specialised services, providing ward education on hypoglycemia, routinely checking CBG (along with other drugs), and ensuring that appropriate therapy modifications are made when iatrogenic hypoglycemia occurs. The possibility of expanding the role of hospital pharmacists should be explored to see whether this might assist in reducing the burden of inpatient hypoglycemia, especially in cases where they could be supported and trained in terms of ward outreach and teaching. Increasing the number of hospital beds Pharmacist involvement may complement current expert outreach initiatives by providing local support to ward physicians and other healthcare professionals in managing the high frequency of diabetes issues seen in the hospital setting. This may be done by conducting a more thorough examination of prescription processes and, if required, implementing and monitoring patient "sick-day" limits as well as other measures. This would provide an additional layer of protection for the patient's well-being as a result. In the event if pharmacists worked more directly and directly with patients as mentors, they could be more knowledgeable of their disease, treatment, suggested therapeutic requirements, and the need of concordance.

Pharmacists play an essential role in the “multidisciplinary team” approach to healthcare (MDT). This goal may be best achieved via the use of MDT meetings to address any issues with ward teams and to turn any times of inactivity or mistake into chances for collective learning. Pharmacy professionals may also participate in department and trust-level safety huddles to assess the effectiveness of rescue measures performed and any local or systemic vulnerabilities that have been identified in the treatment of diabetic patients with hypoglycemia, among other things. Separate studies on individuals with severe and non-severe hypoglycemia may be beneficial in improving our knowledge. Patient morbidity and mortality are impacted in two distinct ways under these two scenarios. As a consequence, the relative importance of urgent treatment, specialist advice, physician or pharmacist requirements, and recurrence concerns should all be considered in tandem. If a follow-up research could be conducted to investigate hypoglycemia treatment inequalities and the efficacy of tailored outreach and follow-up methods, it would be very helpful. In-patient diabetes treatment programmes that are of high quality, with an emphasis on correctly treating and avoiding hypoglycemic episodes, may assist to decrease morbidity and mortality in diabetic patients. In this way, it is believed that the overall implication of the study mainly suggest giving training to healthcare professionals to reduce the risks associated with Hypoglycaemia, and thus offer better healthcare and patient-care services.

7. Conclusion and Recommendations

In this study, it is demonstrated that inpatient hypoglycemia is quite common and the suboptimal treatment accorded to hypoglycemia is also highlighted. There are numerous factors that have associations with hypoglycemia`s development and the majority of them present opportunities that could be targeted for interventions with immense benefits. In a nutshell, it has been concluded that when symptoms appear of inpatient hypoglycaemia, the patient should be encouraged to consume simple carbohydrates as soon as possible. It is possible that increased pharmacist involvement in diabetes care may assist to alleviate the problem of insufficient inpatient diabetic treatment. Greater pharmacy staff participation may be achieved by improving communication with specialised services, informing patients on hypoglycemia, routinely monitoring CBG (as well as other medicines), and changing therapy when iatrogenic hypoglycemia occurs on the ward. Increasing the participation of hospital pharmacists in ward outreach and education may help to reduce the burden of inpatient hypoglycemia, especially if they are given the necessary assistance and education in this area. Nurses, doctors, and other health-care professionals must be on the lookout for hypoglycemia in diabetes patients and be diligent in identifying, treating, and most importantly, avoiding it. Diabetes treatment systems and procedures assist the health care team in reaching glycemic objectives for healing and health promotion while maintaining a safe environment for individuals with the disease. Moreover, the findings revealed from the research revealed that diabetes outpatient therapy has long recognised the significance of glucose control in the management of the disease. When adequate dosages of any oral glucose-lowering medications are taken to control blood glucose levels, severe hypoglycemia is unlikely to develop except in the case of prolonged fasting. In this way, it becomes evident that effective treatment can help in resolving this health-related issue. On the other hand, it is also essential to note that the implication of the proposed treatment methods for hypoglycaemia is not enough if nurses are not given proper assistance and consideration by leadership in the healthcare institutions. In this regard, it has been appraised that a democratic leadership style should also be introduced within the healthcare institution to make sure that the leader involves nurses and other healthcare professionals in the decision-making process to decrease the incidence of patients developing hypoglycemia. All nurses must be trained accordingly in order to offer better patient-care facilities, and thus improve the overall rate of recovery as well.

8. Reflection

Notably, this study has provided me with the chance to get acquainted with the concept of identifying all of the key modifiable risk variables that may be modified in order to decrease inpatient hypoglycemia. Nonetheless, I would like to point out that I have gained some project management abilities as a result of working on this particular project. For example, I am now fully familiar with the research reporting procedure as well as the data collecting process. I believe that my respective managerial abilities, along with my established time-management skills, have the credibility to make a positive contribution to the improvement of my work practises. For example, if I am hired by a practical company, I will be able to produce a very effective research report and I will make every effort to complete all of the duties within the specified time frame. I will be successful in my future project attempt if I follow this strategy. Aside from that, I'd want to share some thoughts on my experiences working with larger networks and with colleagues. Previously, I was very timid and didn't feel at ease when I had to collaborate with people. Although I learnt how to interact with people and exchange ideas with them as a result of my participation in this project, my main goal was to finish the project as a result of my participation. This specific method is meant to assist me in a major way in finishing my assignment, and I feel that I have grown in responsibility as a result of my ability to accomplish difficult work on time and make important choices. Thus, I consider myself to have gained the ability and capability to lead and assume responsibility for future project development because I am able to use my learned interpersonal and professional skills to make sound decisions and collaborate with others to complete the project on time, as demonstrated by my participation in this project.

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