SHM Converge Scientific Abstract ePoster Gallery-Hypoglycemia Reduction on Medicine Floors at Memorial Hermann Hospital- Texas Medical Center

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This quality improvement project at Memorial Hermann Hospital–Texas Medical Center aimed to reduce inpatient hypoglycemia on medicine floors, ICU, IMU, and med-surg units, where rates were higher than at similar academic hospitals. Hypoglycemia was defined as blood glucose ≤50 mg/dL in patients receiving insulin.

The team performed chart review and root cause analysis from June 2023 to February 2026 and identified common risk factors including NPO status, tube feeding, type 1 diabetes, renal dysfunction, and poor oral intake. They then used three PDSA cycles:

1. <strong>PDSA cycle 1 (April 2024):</strong> Sent feedback emails to clinical teams after each hypoglycemia event, asking why it happened and how it might have been prevented.  
2. <strong>PDSA cycle 2 (October 2024, during EMR transition to Epic):</strong> Developed new insulin and hypoglycemia order sets to improve standardization and safety.  
3. <strong>PDSA cycle 3 (October 2025):</strong> Focused on resident education through a tip sheet on insulin dosing and hypoglycemia prevention, shared via email, team rooms, and ward teaching sessions.

Results showed a baseline average of <strong>4.3 hypoglycemia cases per month</strong>. After cycle 1, rates fell to <strong>3.0/month</strong>. After cycle 2, the rate was <strong>3.5/month</strong>, possibly reflecting adaptation to the EMR transition, but still better than baseline. After cycle 3, the rate improved further to <strong>2.0/month</strong>, suggesting benefit from resident education.

Overall, the project suggests that feedback emails, standardized order sets, and targeted education can reduce inpatient hypoglycemia. The next step is to create an EMR alert that prompts providers to reassess insulin when diet orders change.

Asset Subtitle

Evan S. Leung

Meta Tag

Author List Adrienne DaGue, Aiden Strother, Ayesha Safdar, Esthelory Lopez Hidalgo, Evan S. Leung, Jeffrey Chen, Jeffrey Cleaver, Jiaqi Gu, John Beetz, Mary-Catherine Nesby, Matt Smithhart, Natalie Bush, Rose Yeh, Samuel Hong, Sydney Smithhart

Category Innovations

Concept Hypoglycemia

Concept Iatrogenic Hypoglycemia

Concept Fasting

Concept Tube Feeding

Concept Poor Oral Intake

Distinguished Non-Finalist

Presenter Organization UT Houston McGovern Medical School - Houston, TX

Presenting Author Evan S. Leung

Track Quality Improvement

Keywords

inpatient hypoglycemia

quality improvement

PDSA cycles

insulin safety

order sets

Epic EMR transition

resident education

blood glucose

medicine floors

hypoglycemia prevention

Hypoglycemia

Iatrogenic Hypoglycemia

Fasting

Tube Feeding

Poor Oral Intake