RESEARCH POSTER PRESENTATION DESIGN © 2015 www.PosterPresentations.com Oral Glucose Gel: Low Cost, Quick and Effective Management of Neonatal Hypoglycemia In a continuous endeavor to maintain best practice for neonatal care, increasing and maintaining exclusive breastfeeding rates stays at the forefront of our perinatal department’s agenda. With the intention to lower the rate of separation of mom’s and babies, and positively impact breastfeeding we joined forces. In collaboration with all perinatal areas, lactation, pediatrics, neonatology, information systems and the families we serve, in July 2017 we launched the use of oral glucose gel for treatment of neonatal hypoglycemia. Evidence was presented to all staff (Harris,etal, 2013)( AAP, 2011 ). Following AAP guidelines an algorithm was established, policy and practice were updated and the staff trained one on one. Through two quarters we fine-tuned our data collection, adjusted to the unexpected new glucometers, and managed to drop our rate of admission to NICU with a primary diagnosis of hypoglycemia from 12% to 3% of all hypoglycemic neonates born at our community NICU. INTRODUCTION OBJECTIVES A Gap analysis early in the project revealed a general lack of knowledge, absence of dextrose Gel in the institution, and a clear ordering method. As the project was adopted by the Pediatric committee and the unit based nurse committees from Couplet Care, the NICU and lactation teams, the need for a strong multilevel education plan became clear. All stakeholders including the pharmacy and information technology team would be involved. A GANNT chart kept us abreast of our progress, and leaders from every area kept the conversation alive with monthly updates avoiding a surprise practice change for all staff involved. Major Goals Met- 15 months 1. Buy in from Neonatology 2. Creating a Policy: Many revisions 3.Add 40% Dextrose Gel to formulary a) Pricing b) Stock in medication dispensing machine c) Documentation in EMR d) Multi-dose tube scanned with every administration 4. New order: added to hypoglycemia order set a) Originally not pre-checked b) Pre-checked as Physician confidence grew c) Originally physician notification with every dose 5. Staff Training: a) New algorithm b) Pharmacy training c) Medicine: 95% communication by phone with pediatricians d) Neonatology: awareness of process and availability of product in nursery e) IT: Training all users to utilize the order f) Nursing: Gel administration, 1:1 hands on training, blood sugar follow up, and team communication and support METHODS AND MATERIALS CONCLUSIONS & DISCUSSION The use of oral Dextrose Gel is a viable, cost effective method of treating neonatal hypoglycemia. Within 3 fiscal quarters, the rate of babies with hypoglycemia admitted to NICU dropped from 12% to 3%. However, the target is moving and difficult to stay ahead of. With differing recommendations for “normal blood Sugars”, and the pressing issue of exclusive breastfeeding this algorithm remains a hot topic. • With the First two patients receiving gel, the second blood sugar remained below 30 mg dL, thirty minutes after the dextrose gel dose. They were taken to NICU for IV Dextrose, but blood sugar in NICU was> 60 g/dL, the baby went back to the mother, and we lengthened the interval between dose and recheck of blood sugar. • The first ever dose of glucose gel given was on a weekend. It was requested by a pediatrician. The staff were annoyed that it was so hard to obtain- because go live was not until Monday. The pharmacist found it and a dose was given, keeping the baby with the mother. Go Live that Monday, took care of that. • Originally, Staff needed to notify the pediatrician for an order prior to every dose. This generated too many calls and the algorithm was adjusted REFERENCES AAP (2011). Postnatal glucose homeostasis in late-preterm and term infants. Pediatrics 3 (127). Retrieved from http://pediatrics.aappublications.org/content/127/3/575.short Bennett, Fagan, Chaharbakhshi E, Zamifirova, & Flicker (2016). Implementing a protocol using glucose gel to treat neonatal hypoglycemia, Nursing and Women’s Health. 2016 Feb- Mar;20(1):64-74.doi: 10.1016/j.nwh.2015.11.001 Epub, 2016 Feb 12. Cochrane Review, (2016). Oral dextrose gel for treatment of newborn infants with low blood glucose levels. Retrieved from: http://www.cochrane.org/CD011027/NEONATAL_oral- dextrose-gel-treatment-newborn-infants-low-blood-glucose-levels Harris DL, Weston PJ, Signal M, Chase JG, & Harding JE ( 2013). Dextrose gel for neonatal hypoglycemia randomized, double blind, placebo-controlled trial. Lancet. 2013 Dec.21;38(9910):2077-83. doi: 10.1016/S0140-6736(13)61645-1 Office of the surgeon General (2011). The surgeon general’s call to action to support breastfeeding. Publications and reports of the surgeon General. Retrieved from: https://www.surgeongeneral.gov/library/calls/breastfeeding/index.html WHO (2010). Health Topics: Breastfeeding. Retrieved from: http://www.who.int/topics/breastfeeding/en/ ACNOWLEDGEMENTS AND CONTACT Sharon McMahon APRN, CNS- [email protected] Mary Beth Sweet, IBCLC- [email protected] Mary Welch, BSN, RNC-NIC [email protected] Sally McGann, Director, HMNH Perinatal, [email protected] Newborn Pediatric Committee HMNH It has been amply demonstrated that exclusive breastfeeding positively impacts the health of both mothers and babies (USDHHS, 2011). In our community hospital, while approximately 400 bedside neonatal blood sugars per month are checked secondary to risk factors for hypoglycemia or demonstrations of symptoms of low blood sugar (AAP, 2013), only about 10 % of those patients are admitted to NICU for hypoglycemia. These newborns are separated from their family negatively impacting their ability to establish exclusive breastfeeding during the newborn inpatient stay. In an effort to keep mothers and babies together and allow optimal opportunities for skin to skin, preservation of the family unit, and unlimited access to breastfeeding, oral Dextrose gel for treatment of neonatal hypoglycemia was implemented. Henry Mayo Newhall Hospital Sharon McMahon APRN, CNS NICU Mary Beth Sweet, IBCLC Addressing Barriers to Exclusive Breastfeeding Keeping Moms and Babies Together: Dextrose Gel and Neonatal Hypoglycemia Evidence HMNH ALGORITHM RESULTS Within 3 fiscal quarters, the rate of admission to NICU for hypoglycemia dropped from 12% to 3%. The total number of necessary blood sugars for newborn nursery and NICU combined dropped 20%. DOSE: 0.2 grams Glucose / kg / dose (D10W = 0.1 gram / mL) Glutose Gel = 0.4 gram / mL STAFF EDUCATIONAL POSTER - - Dextrose is Glucose is Dextrose Weight in kg Dose of 40% Oral Gucose Gel in grams Volume, mL 2 0.4 1 2.5 0.5 1.25 3 0.6 1.5 3.5 0.7 1.75 4 0.8 2 4.5 0.9 2.25 5 1 2.5 Asymptomatic with Risk FactoRS: Infant of Diabetic Mother (IDM) Large for Gestational Age (LGA) or BW ≥ 4000 grams Small for Gestational Age (SGA) or BW ≤ 2500 grams Late preterm: 35 0/7 – 36 6/7 weeks gestation Symptomatic Any Time During Stay: Jittery, tremors, seizures Lethargy, poor feeding Apnea, respiratory distress Hypotonic, floppy, irritable Exaggerated Moro High pitched, feeble cry BIRTH Immediate Skin-to-Skin and Assist with Breastfeeding POCT #1 After Breastfeeding, within 1 hour of birth Immediately upon demonstration of symptoms RESULTS: Bedside glucose check = POCT Encourage mom to hand express and feed back any available EBM in Addition to any other feeding orders Less than 30 mg /dL Give a dose of Oral Glucose Gel 0.5 mL/kg per policy Give supplemental formula feeding 15-30 mL Keep baby Skin-to-Skin, continue assisting with breastfeeding, hand expression and feeding back any EBM or 31 – 39 mg / dL Give a dose of Oral Glucose Gel 0.5 mL/kg per policy Keep baby Skin-to-Skin and continue assisting with breastfeeding, AND hand express and feedback any EBM or Greater than 40 mg/dL Continue feeding every 2-3 hours and check blood sugar before every feed for 24 hours Continue feeding every 2-3 hours and check blood sugar before every feed until 3 consecutive results are greater than 45 mg/dL POCT #2 1 hour after last POCT-at least 45 minutes after gel dose Less than 30 mg / dL Give a dose of Oral Glucose Gel 0.5 mL/kg per policy Give supplemental formula feeding 15-30 mL Keep baby Skin-to-Skin, continue assisting with breastfeeding, hand expression and feeding back any EBM If this is the second sugar <30, Notify MD and consider transfer to NICU or 31 – 39 mg / dL Give dose of Oral Glucose Gel 0.5 mL/kg per policy Keep baby Skin-to-Skin, continue assisting with breastfeeding, And hand express and feedback EBM or Greater than 40 mg/dL Continue feeding every 2-3 hours and check blood sugar before every feed for 24 hours Continue feeding every 2-3 hours and check blood sugar before every feed until 3 consecutive results are greater than 45 mg/dL POCT #3 1 hour after the last POCT- at least 45 min after gel dose Less than 30 mg / dL Immediately Give a dose of Oral Glucose Gel 0.5 mL/kg per policy with supplemental formula feeding 15-30 mL Keep baby Skin-to-Skin and continue assisting with breastfeeding If this is the second sugar <30, Notify MD and consider transfer to NICU or 31 – 39 mg / d Give a dose of Oral Glucose Gel 0.5 mL/kg per policy Keep baby Skin-to-Skin, continue assisting with breastfeeding, hand expression and feeding back any EBM (Up to 6 doses of Glucose Gel may be given within the first 48 hours of life) or Greater than 40 mg/dL Continue feeding every 2-3 hours and check blood sugar before every feed for 24 hours Continue feeding every 2-3 hours and check blood sugar before every feed until 3 consecutive results are greater than 45 GEL+ Formula+ BF GEL+ BF GEL+ BF GEL+ BF GEL+ Formula+ BF GEL+ Formula+ BF