Preventing Hypoglycemic Emergencies in Nursing Homes
Could low blood sugar lead to a life-threatening emergency in a nursing home? Hypoglycemia is often missed until it’s too late, especially in residents with diabetes. Quick recognition and proper care protocols can make the difference between life and death. In this week’s episode, nursing home abuse lawyer Rob Schenk welcomes guest Sharon Bautista to talk about how hypoglycemic emergencies happen, and what nursing homes should do to prevent them.
Bautista:
A person would get a tremor when it’s headed down there, a little bit irritable, like all of us. You can feel that hangry from irritability to like lethargy and listlessness. A little bit of tremors, right? And I would say level of consciousness change, which is the big thing because when you have that, you cannot guard your airway.
Intro
Schenk:
Hello out there. Welcome back to the Nursing Home Abuse Podcast. My name is Rob. I’ll be your host for this episode. Today we are talking about hypoglycemic. Emergencies in nursing homes, what hypoglycemia is, when it becomes a problem, and how it presents in the average nursing home resident. But we’re certainly not having that conversation alone ’cause I couldn’t do it.
Schenk:
As I mentioned, we’re talking about hypoglycemia in nursing homes, how it’s treated, how to prevent emergency episodes with it, but we’re not doing that alone.
We have the fantastic Sharon Bautista. Sharon actually it’ll be a link in the show notes, but Sharon has a really interesting article about hypo hypoglycemia and a field study. It’s a very interesting read. I would highly recommend if you’re interested in this topic, to go and check that out.
Again, it’ll be in the show notes. And I say show notes. I really don’t even know what show notes are. I don’t even know why I say this. If you go to where the quote unquote show notes are and it’s not there, then you’ll have to go to our website. I’ll say that it’ll be somewhere, it’s somewhere.
Maybe even just type in Sharon Bautista legal nurse and hypoglycemia. Maybe it comes up, but definitely if you go to the show notes, wherever that is and it’s not there, go to our website and it’ll be there. I promise that I can promise. I’m in control of the what’s on the website. I’m not in control of this mythical place called show notes.
Anyway, here we go. Sharon is a practicing register, has been a practicing registered nurse since 1991, and the proud owner of LawMed Legal Nurse Consulting a. A firm that helps personal injury and medical malpractice attorneys with their most complex cases. Lamed is located in Cheyenne, Wyoming, serving northern Colorado, Fort Collins, Metro, and Denver locally, as well as many clients on a nationwide basis.
So even if you’re not located in that area where the buffalo roam, Sharon can still help you. Sharon is known, or Sharon’s tagline is the objective detective. Deciphering the medicine and we’re so happy to have her on the show today. Sharon, welcome to the show.
Bautista:
Hi there. Thanks for having me. It’s exciting.
Schenk:
When we are on our end of the show, we are trying to locate guests.
When we send the email out to confirm, we will ask the guests to help us with any pronunciation problems. And what I think is interesting is that you said that your name is Batista, not like the Cuban dictator. From, I don’t know, 75 years ago as opposed to Batista, the current actor who was in Guardians of the Galaxy and stuff.
It’s like a generational, it’s a generational pronunciation of Batista. So I thought that was just,
Bautista:
I guess so I, I used to have people ask me, are you related to the Cuban dictator? So it stuck in my mind, but then try to avoid that affiliation. And then I see in the notes though, that you say no. We’re from Queens. We’re from Queens. It’s not us.
What is hypoglycemia, and why is it particularly dangerous for nursing home residents?
Schenk:
Exactly. Right on. Thank you so much Sharon for coming on the show to talk to us today. So I just want to start off very broadly Okay. And just have you tell us. What is hypoglycemia and hypo? Hypoglycemia? I gotta learn how to pronounce it first. Hypoglycemia. And why is it dangerous for a nursing home resident?
Bautista:
Absolutely. Hypoglycemia is the level of glucose in the circulating blood. And when we’re speaking about circulating blood, we mean blood that’s going to be supplying the tissues and the organs of the body.
So what I mainly think of and what is mainly affected is the brain, which needs a, actually needs quite a large amount of sugar to operate. So the patient or the person, us we can have executive function, decision making and alertness. And along with the alertness comes with, metabolic function in all of our cells for a TP and making energy and, so we generally look at a number about 70 as being low. However, sometimes symptoms might not show up until around 55, according to some literature. And then I’ve seen patients show some or come to me and complain about feeling a little woozy and a little lack of consciousness at around 80 to a hundred just because they’re used to high numbers.
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So with blood glucose you wanna avoid any. Dips, peaks and valleys. You wanna be on more of a level playing field throughout the day. So you, anyway, I could get into all of that. But basically the danger was your question would be a decreased level of consciousness, which is what I have caught in certain places I’ve worked that will remain unnamed.
And. With that comes a risk of aspiration. Because they’re not controlling their airway and they can’t control their airway. It also could make them confused and prone more to falling. So it’s all related. All of the nursing home problems are related and we forget about nutrition and hydration a lot.
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Schenk:
Sure. So let, and let me back up and make sure that I got it. So the hypo is, it’s the, when the blood sugar is too low or too high or both.
Bautista:
Too low.
Schenk:
Too low. Okay.
Bautista:
And the reason I mentioned too low is because, sometimes what happens it, it can be nutritional. Also, if we give someone something super high in sugar and it’s, it spikes their glucose level, what can happen is the pancreas can react and shoot out a whole bunch of insulin and drop that patient drastically.
I see. Some people are brittle, diabetics, what they call brittle diabetics, and they can have a very wavy, instead of having that homeostasis and level playing field for the sugar and energy throughout the day and alertness, they have these peaks and valleys which are dangerous and the valleys are a little bit more dangerous.
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Schenk:
I see.
Bautista:
In the short term.
What are the most common causes of hypoglycemic emergencies in nursing homes?
Schenk:
So what are typically, in your experience, what are the most common causes of hypoglycemia in a nursing home? Is it like just. Giving them the wrong food or wrong medication.
Bautista:
It’s a combination of a couple of things that families and practitioners should be watching for.
The first thing is really, what is their intake like? First of all, are they able to take in intake? Has their condition changed? Because by the time a patient’s in a nursing home they’ve probably had some really debilitating thing happen to them. They’re deconditioned. They may have had a stroke, they may not be able to feed themselves.
So what I have, what I saw in the hospital, which transfers to the nursing home, and I’ve also seen there is a tray will be. Delivered. Tray of food will be delivered to the room and it may not get to the patient, or it may get to the patient’s table and sit there. So you and I both know that I’m the licensed personnel as the nurse.
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And you have CNAs helping. So the unlicensed personnel, it is our responsibility as nurses to delegate educate. Make sure that we’re following up and monitoring because ultimately it’s our responsibility. Make sure that person is getting a meal. Now, whether or not they’re taking an oral, anti-diabetic medication or insulin, or a combination thereof, which happens a lot, you’ll have mon metformin po and also insulin.
You’ll have several different insulins with different peak times. Even if they’re not on any of those, if they’re not having intake, they’re, they are will become hypoglycemic. Then you have the pharmacist, so intake number one, and then you have the pharmaceutical interventions. Which I think sometimes the physicians need to update, I would say on rounds on a weekly basis.
How’s this patient doing? Is their mentation the same as when they came in? Has their intake diminished? Do they like the food? Are they able to feed themselves and have the CNAs been taught to make sure this patient eats? The other part of that, and I hope I’m not being too verbose is that nurses, when they’re drawing up.
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The scheduled insulin, they need to be knowledgeable enough. And I’ve made cheat sheets for myself just to remember when things peak, because there are so many. And when I graduated back in 1991, we didn’t have that many different insulins, short acting, medium acting, long acting, so knowing that and not giving that.
Unless you know this patient has a scheduled snack coming, they’re able to eat it. They have been eating it, looking at the dose, and I always taught my nursing students, I’ve done some teaching instructing and I always say before you give a medication, when you draw it up, you’re doing all the five rights of medication administration, then you’re.
As you’re walking into the room, you should be saying, why am I giving this right now? Does my patient still need it? Is everything safe that I’m about to do? And one of those checks is when is there next intake of any kind of nutrition whatsoever?
Schenk:
I see. So there,
Bautista:
There are EMRs that have a fail safe matrix. Sure. Which I’m using right now. I’m punishing myself by working some nursing home shifts, and I don’t say it’s a punishment because of the patients, it’s the nurse patient ratio. That’s punishment. Sure.
Schenk:
No, trust me, pharmacy, we, we are aware of that on this show. Yeah. So let me let me interject so I, so we can make sure we’re all on the same sheet of music.
You’ve got hypoglycemia. But when does it actually become an emergency? Because I’m assuming that there’s some level of hypoglycemia that it’s allowable, it’s acceptable, and then or maybe not. See, you’re shaking your head, so that’s great. So the let please educate me, like when is it, when do we get from, it’s a problem to, it’s an acute care facility problem.
Look at discharge.
Bautista:
Sure thing. I would say level of consciousness. It should be the way I was raised in nursing. In New York, we had very strict instructors is you head stuff off at the pass, you don’t practice reactive medicine. You try to anticipate what could happen. Monitor, it’s a constant loop.
The nursing process. You’re constantly evaluating what you’ve done and monitoring, rechecking, revising the plan of care. So it really shouldn’t happen that often. If you’re paying attention. Sometimes the nurse patient ratio does plug in, but if you have your nurse’s aides trained, it can help.
To answer your question about what is considered hypoglycemia that may. Not be a severe hypoglycemia or an emergency where the patient just says, I feel a little tired and they’re a little cold and clammy. I feel like my sugar’s low. Or you notice a change that could be around, 80 or a hundred for some people around that 70 mark.
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Where we’re getting into danger with level of consciousness and therefore risk of aspiration and other issues of falling and confusion. It mostly has to do with how it affects the brain. So you’re getting into the 55, 40, I’ve seen 30 where we have to go to the crash card in hospitals and rarely in nursing homes.
But and give that patient iv. Dextrose in the nursing home, they don’t have IVs. So I see a lot of people trying to give the patients sips of juice. That’s all fine and good, but it’s going to spike them and they’re gonna be down again, right? So they just need nutrition. If you don’t mind, the other factor is.
Are they swallowing well? Can they still swallow? Have they deteriorated since they came in? Are they sleeping well? Maybe they really don’t feel well. How’s their speech and swallow mechanism? Maybe they just can’t take the food or every time they try their choking and it hasn’t been reevaluated.
So they need a nutrition consult and they need a speech language pathologist consult, and that’s something we need to alert the physician. So the patient’s not eating or not able to eat, and that has changed we’re, it’s our responsibility to be in touch with the physician, even let the family know. And sometimes the patients don’t like the food.
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Schenk:
That’s true. That happens. We’ve got lethargy, maybe loss of consciousness, maybe feeling rundown or exhausted. Are there any other symptoms of hypoglycemia that we should be looking out for?
Bautista:
There would be tremors sometimes. A person would get tremory, first of all when it’s headed down there a little bit irritable, like all of us right.
When we really need a meal like nurses who don’t get breaks. Yeah. You can feel that hangry. So if you notice any of that, then, it descends from there. From irritability to like lethargy and listlessness a little bit of tremors. I would say a level of consciousness change, which is the big thing because when you have that, you cannot guard your airway.
If they attempt to get up to go to the restroom, they’re probably gonna fall like higher risk. And then you could have coma and death from no blood sugar.
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How do facility staffing levels and shift handoffs contribute to lapses in glucose monitoring or missed insulin timing?
Schenk:
Okay. So we’ve talked about it. Staffing. Okay. And how, staffing typically can lead to negative outcomes, particularly with hypoglycemia.
But talk to me about the concept of shift change and handing the resident off to a new shift. And what challenges that present?
Bautista:
I’ve seen it done poorly in some places and I’ve seen it done well in others. More recently where I have been doing some shifts. In the place I currently work let’s be positive about the good one.
The nurse to nurse report happens. It’s in Matrix where we are monitoring intake. We’re offering snacks on a schedule, especially to the diabetics, right? If we’re giving the evening insulin, they usually have an evening snack of some sort, and it’s on there as a task with the medication, so that helps.
So even if the nurse doesn’t mention to you, oh, they’re not eating, you can see it when you go through the tasks. They should be talking to each other about head to toe. But when you have 20 patients in a nursing home, the nurses generally aren’t doing a head to toe assessment. They’re giving awake, alert, and oriented how they transfer, what’s the third thing, how they take their pills, do we need to crush them?
That kind of thing. And it’s really fast and you have to do your own research. The other part that’s positive where I work now is the CNAs report to one another. Oh, how does this patient transfer? How was, how were they today? Are they incontinent? Did they have a bowel movement? And we, and they closely speak to us.
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We have to monitor their bowel movements because once you’re constipated, you stay constipated. It’s very hard to go. I would say that it’s very good where I am and very poor elsewhere, and you can’t rely on your chart. You have to rely on your patient and some kind of handoff report. So usually when I give report and I’m giving it on 20 patients, I, you’ve heard of charting by exception.
When something out of the ordinary happens, you document on that. I always read a narrative on each of my patients. It can be a few sentences unless something big happened. You can chart an event, and I always report that way, anything out of the ordinary from this patient because sometimes the nursing home patients are known to the nurses.
So anything out of the ordinary for that patient that day is given in report should be given in report.
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What role do families play in helping to prevent hypoglycemic events in their loved ones?
Schenk:
So imagine that you’ve got a family of a loved one in a nursing home. What advice would you give them with respect to preventing any type of emergency hypoglycemic events?
Bautista:
Sure. How are they eating?
If you’re making a phone call, do you know if they ate today? Do the, did the nurses’ aides, log it? Does the nurse know? Are they drinking water? If you’re visiting, I would say try to be there at meals. Watch yourself, help them bring them something. If you’re allowed and they’re not on a special diet, bring them something that you know they like as long as it’s, you’ve checked and it’s in the consistency for swallowing and safe, right by order.
But I would say inquire if it’s over the phone. Observe when you’re there, see how their swallowing is. If they like the food, ask them how they’re doing with their meals and ask the staff. If they’re on insulins, they can, even, the family members can ask the doctors, Hey, the nurses told me that the sugar was really low in the morning.
Sometimes patients are hard to arouse in the morning because they didn’t get that nighttime snack. They got a long acting insulin and. People say, oh, they’re really tired today. No, their sugar is probably low. And then the fasting sugar is always low.
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Schenk:
Right?
Bautista:
You can ask the physician, do you think maybe they could be adjusted in their insulin little bit? They’re eating a little less. Now, can we lower the sliding scale and the dosages of the, these insulins? And that is something they, it’s not their responsibility. The nurse should be doing that. But if the family members wanted to be armed, that might help.
Schenk:
It’s good to have an extra set of eyes on your loved one.
Yes. Sharon, we really very much appreciate you coming on the show and sharing your knowledge with us today.
Bautista:
Thank you for having me. I loved your podcast. That’s why I reached out to you to just compliment you. And I do thank you for asking me and having me on.
Schenk:
Oh, thank you. Folks, I hope that you found this episode educational.
And again, be sure to check out Sharon’s article on this topic. Very interesting read. And if you have an idea for a topic that you’d like for me to discuss, please let me know. If you have an idea for someone you’d like for me to talk to, please let me know that. As well, new episodes of the Nursing Home Abuse podcast come out every single Monday.
Be sure to enter into the nursing home regulation question of the week. Win yourself a mug but let’s face it, you’re not going to, and that’s perfectly fine. I basically have settled into that now. I’m gonna have a couple boxes of these for a while. Put a couple boxes of. Mugs for a while. So anyway alright folks.
I guess that’s it. New episodes every Monday. Did I already say that? New episodes of the Nursing Home Abuse Podcast come out every single Monday with that folks. We’ll see you next time.
Sharon Bautista’s Contact Information: