|Home | About | Journals | Submit | Contact Us | Français|
I read with extreme interest the original article titled “Study of a structured action pathway and persistent monitoring tool among nurses to achieve cent percent management of hypoglycaemia in in-patients: A measure of quality of healthcare” by Mishra et al. published in Med J Armed Forces India 2016;72:27–32.1
The authors have studied an important aspect of in-patient care and intervened to improve the management of in-patient hypoglycemia by a systematic introduction of a protocol to enable the para-medical staff to act in the golden period to minimize morbidity and mortality associated with this dreaded complication of hyperglycemia management. This practical application can be implemented in all hospital settings for improving quality of care.1
However, the study has many weaknesses, which I would like to highlight:
Data were extracted from hospital records, patient case records, and hospital Quality Flash matrix (QF) in terms of total number of cases receiving insulin and total number of episodes of hypoglycemia documented and reported. Patients on oral hypoglycemic alone were left out, although they form a large subset of in-patients with hypoglycemia.
The data on hypoglycemia have been derived from hospital records retrospectively after a period of time and not in real-time.
The source of data on “actual episodes of hypoglycemia” recorded on QF has not been clarified and it is not clear as to how are these different from “nurse documented hypoglycemia”.
References on incidence of hypoglycemia episodes on insulin therapy and its management are old and are from the times when human insulins, NPH, and lente insulins were used.2 These insulin preparations had a greater propensity to cause hypoglycemia. Newer basal analogs have relatively flat time-action profile and ultra-short acting analogs, which are used as prandial insulins, have far lesser incidence of hypoglycemia.
Indications for using IV dextrose or inj. glucagon and choosing one over the other have not been clearly defined.
The authors have used the term “Adolescent Diabetes” in exclusion criteria, which is not a standard terminology in classification of DM. Instead, they should have justified exclusion by age criteria or Type 1 DM. Justification for excluding women with gestational diabetes who form an important subset of diabetic population who are primarily on insulin therapy has not been adequately provided.
It is gratifying to see the reader's interest in the original article. Certain aspects of the study need to be put in perspective to understand the context of the study.