exercise therapy – management of hypoglycaemia and ... · web viewclinician discretion is...

CHHS18/117

Canberra Hospital and Health ServicesClinical Procedure Exercise Therapy – Management of Hypoglycaemia and Hyperglycaemia for Patients with DiabetesContents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Monitoring of Blood Glucose..................................................................................2

Section 2 – Hypoglycaemia.......................................................................................................4

Section 3 – Management of Hypoglycaemia.............................................................................4

Section 4 – Hyperglycaemia......................................................................................................5

Section 5 – Hyperglycaemia Management................................................................................6

Section 6 – General Exercise Considerations............................................................................6

Implementation........................................................................................................................ 7

Related Policies, Procedures, Guidelines and Legislation.........................................................7

References................................................................................................................................ 8

Search Terms............................................................................................................................ 8

Attachments..............................................................................................................................8

Attachment 1 – Nova StatStrip Blood Glucose/Ketone Skills Assessment Form.................10

Doc Number Version Issued Review Date Area Responsible PageCHHS18/117 1 20/03/2018 01/04/2022 Medicine – Acute

Support1 of 11

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS18/117

Purpose

The purpose of this procedure is to provide clinicians with information on the safe and effective management of hypoglycaemia and hyperglycaemia for patients with diabetes undergoing exercise therapy within ACT Health facilities.

The procedure provides clinicians with best practice information for assessment and management of patients with diabetes experiencing hypoglycaemia or hyperglycaemia.

Back to Table of Contents

Scope

This document applies to adults and adolescents performing exercise therapy as prescribed by suitably qualified health professionals within ACT Health facilities.

This document applies to Canberra Hospital and Health Services (CHHS) staff working within their scope of practice: Allied Health Professionals Nursing staff Allied Health Assistants Allied Health students under direct supervision


Section 1 – Monitoring of Blood Glucose

Equipment Blood glucose monitoring kit – provided by ACT Pathology Personal protective equipment including gloves, goggles

Hypoglycaemia treatment items including juice and crackers. These are sourced from Canberra Hospital’s Food Services and are ordered as needed.

All patients are required to monitor their Blood Glucose Level (BGL) pre and post exercise and as deemed clinically necessary by the treating health professional. Clinician discretion is utilised for patients that are not medicated regarding the monitoring of BGL to assist with the management/understanding of a patient’s BGL in response to exercise.

During the initial consultation staff are to inform patients to bring their own fast and slow acting carbohydrate to each exercise session as a treatment method in the event of a hypoglycaemic episode.

Patients are encouraged to monitor their BGL utilising their personal BGL monitor and consumables to promote self-management. Patients should be encouraged to have their BGL monitor reviewed by their local Pharmacy or location of purchase to ensure it is


Support2 of 11


CHHS18/117

calibrated regularly. If a patient does not have their own BGL monitor or requires assistance with taking their BGL, staff are to assist and utilise the service’s blood glucose monitoring kit.

ProcedureStaff may only perform capillary blood glucose (cBGL) monitoring once they have completed the Glucose/Ketone Monitoring System Competency Test by a suitably trained facilitator (Attachment A).

Ensure the lancing site is clean prior to the cBGL being attended Staff are to document patients’ BGL in the clinical record as per service specific

requirements Staff are required to deem a patient appropriate and safe to commence exercise based

on their pre-exercise BGL and the consideration of a number of factors including:o Ageo Duration of diabeteso Type of medication prescribed to assist in the management of diabeteso Other medical conditions

It is recommended that the Initial Assessment Checklist – Diabetes (located on the Clinical Forms Register) is utilised at Initial Assessment to gather important information regarding the patient and their diabetes to assist clinical decision making.

Target ranges will vary depending on the individual and an individual’s circumstances. Patients should be encouraged to seek advice from the Diabetes Educator, Endocrinologist or General Practitioner to determine individual target levels.

Glucose level targets (during and outside of exercise)Target levelsType 1 Diabetes (T1DM) 4-8mmol/L before meals

<10mmol/L two hours after starting a mealType 2 Diabetes (T2DM) 6-8mmol/L before meals

6-10mmol/L two hours after starting a mealPatients with type 2 diabetes who are not taking sulphonylurea medication should aim for a blood glucose as close to normal as possible 4.0-7.8mmol/L.Risk of hypoglycaemia (Type 1 and Type 2 diabetes)

<4mmol/L if insulin or sulphonylurea/multiple diabetes medications have been prescribed. This does not apply to individuals on metformin only or individuals who are not medicated for diabetes.

Adapted from Diabetes Australia Website 2018



Support3 of 11


CHHS18/117

Section 2 – Hypoglycaemia

Hypoglycaemia is defined as BGL <4mmol/L (1) It is important to treat hypoglycaemia quickly to minimise the BGL from falling lower

and the patient becoming seriously unwell Hypoglycaemia can be caused by one or a number of events, such as:

o Too much insulin or other glucose lowering diabetes medicationo Delaying or missing a mealo Not eating sufficient carbohydrateo Unplanned physical activity (hypoglycaemia may be delayed for 12 hours or more

post exercise bout)o More strenuous exercise than usualo Consumption of alcohol increases the risk of hypoglycaemia; risk is further increased

with higher intakes of alcohol. Symptoms of hypoglycaemia can vary from person to person and can include the

following early signs:o Shaking, trembling or weaknesso Sweatingo Palenesso Hungero Light-headednesso Headache o Dizzinesso Pins and needles around moutho Mood change

If the BGL continues to lower, more serious signs and symptoms may occur including the following:o Lack of concentration/behaviour changeo Confusiono Slurred speecho Unable to treat own hypoglycaemiao Unable to drink or swallowo Unable to follow instructionso Loss of consciousnesso Fitting/seizures


Section 3 – Management of Hypoglycaemia

1. Staff member must stay with the patient at all times to ensure patient safety2. Test and record BGL to confirm hypoglycaemia (if BGL is unable to be monitored, treat

patient as hypoglycaemic)3. Patient to consume 15 grams of fast acting carbohydrate, such as (2):


Support4 of 11


CHHS18/117

6-7 jellybeans OR ½ juice box OR ½ can of regular soft drink (not ‘diet’) OR 3 teaspoons of sugar or honey OR glucose tablets equivalent to 15 grams

carbohydrate4. Wait 15 minutes, re-check BGLs to determine if the patient’s BGL has risen above

4mmol/L. If BGL has risen above 4mmol/L, perform Step 5. If BGL is below 4mmol/L, repeat Step 3.

5. Patient to consume snack or meal with longer acting carbohydrate such as: Packet of Jatz (x3 Jatz biscuits) OR A slice of bread OR 1 glass of milk OR 1 piece of fruit OR 2-3 pieces of dried apricots, figs or other dried fruit OR 1 tub of natural low fat yoghurt OR Pasta OR Rice

6. Thorough documentation should be recorded in the patient’s clinical record7. Assist patient in identifying possible reason for hypoglycaemia episode once BGL is >4.0

mmol/L.

Alert (as per glucose/insulin chart):Hypoglycaemia causing unconsciousness is a medical emergencyFor the patient demonstrating impaired consciousness (drowsy, uncooperative or aggressive) or who is unconscious or unable to swallow where hypoglycaemia is suspected: Follow basic life support training Call Code Blue. Dial 8 or press code button


Section 4 – Hyperglycaemia

Hyperglycaemia is defined as BGL >15mmol/L (6). Hyperglycaemia can develop over many hours or days Common causes of hyperglycaemia include:

o Sicknesso Infectiono Stresso Large quantity of carbohydrate food for one mealo Insufficient insulin or diabetes medicationo Other medications

Symptoms of hyperglycaemia can include the following:o Excessive thirsto Frequent passing of and large volumes of urine


Support5 of 11


CHHS18/117

o Tirednesso Blurred visiono Infections (e.g. thrush, cystitis, wound infections)o Weight loss


Section 5 – Hyperglycaemia Management

For Type 1 Diabetes 1. Monitor BGL to confirm hyperglycaemia2. If BGL is >15mmol/L ketone levels should be monitored3. Ketone levels are considered high if >0.6mmol/L and patients should not

perform/continue with exercise 4. Patient’s with ketone levels >0.6mmol/L should be reviewed by a medical practitioner by

contacting the Endocrinology Registrar or, in an emergency and where clinically indicated, activating a Code Blue

5. Consumption of water is recommended to minimise/avoid dehydration.

Symptoms of ketoacidosis include: Rapid breathing Flushed cheeks Abdominal pain Sweet acetone smell on the breath Vomiting Dehydration

For Type 2 Diabetes 1. Monitor BGL to confirm hyperglycaemia:

It is normal for blood glucose levels to increase and decrease throughout the day. An occasional high blood glucose level is not of significant concern.

If a patient’s BGL remains high or the patient is sick it is recommended that the patient is referred to their Diabetes Educator, Endocrinologist or General Practitioner for review.


Section 6 – General Exercise Considerations

If a patient’s BGL is low staff should treat the patient for low BGL. Potential contributing factors for low BGL may include the patient’s diabetes medication(s), when the patient last ate and what the patient had to eat, prior to commencing hypoglycaemic treatment. Insulin and Sulphonylureas may cause hypoglycaemia. Patients with T1DM are more likely than patients with T2DM to have a hypoglycaemic episode (1, 3)


Support6 of 11


CHHS18/117

If pre or post exercise BGL is <5.5mmol/L, 15-30 grams of carbohydrate should be ingested to reduce the risk of a hypoglycaemic episode during and post exercise for patients on insulin or Sulphonylureas (1, 3, 4, 6)

If patients have diet controlled diabetes or are medicated with Biguanides (e.g. Metformin), Byetta or DPP-4 inhibitors (e.g. Sitagliptin) they should be at a lower risk of experiencing a hypoglycaemic episode. Those patients taking combination treatments, are still at risk of hypoglycaemia. It is recommended that BGL monitoring should be performed midway through the exercise session or as deemed appropriate by the health professionals.

Patients with cardiovascular disease and Diabetes Mellitus on Insulin or Sulphonylureas must have a BGL of >6mmol/L prior to exercising and leaving the Gymnasium (7). If a patient declines this advice, staff are required to document this in the patient’s clinical record

Hypoglycaemia may be delayed 12 hours after exercise (2) Should a patient experience an unexplained hypoglycaemic episode or hypoglycaemic

episodes are becoming more frequent, it is recommended that the patient is referred to or encouraged to make contact with their treating Diabetes Educator, Endocrinologist or General Practitioner for review.


Implementation

Staff supervising exercise therapy will complete Glucose/Ketone Monitoring System Competency Test as conducted by a suitably trained facilitator.

Compliance with this procedure will be monitored by supervision and review of adverse events reported via RiskMan.

Staff education and application of this procedure will occur through orientation programs, credentialing processes and in-services.


Related Policies, Procedures, Guidelines and Legislation

Policies Blood Glucose and Ketone Point-of-Care Testing Procedure Diabetes Management: Including hypoglycaemia, IV, insulin infusions and insulin pumps

(Adults only) policy

Legislation Health Records (Privacy and Access) Act 1997 Human Rights Act 2004 Work Health and Safety Act 2011



Support7 of 11


CHHS18/117

References

1. American Diabetes Association. Standards of medical care in diabetes – 2007. Diabetes Care. 2007; 30:S4-41.

2. Diabetes Australia. Hypoglycaemia web page. https://www.diabetesaustralia.com.au/hypoglycaemia.

3. Sigal RJ, Kenny GP, Wasserman DH, Castaneda-Sceppa C, White RD. Physical activity/exercise and type 2 diabetes: A consensus statement from the American Diabetes Association. Diabetes care. 2006;29:1433-1438.

4. Sigal RJ, Kenny Gp, Wasserman DH, Castaned-Sceppa C. Physical activity/exercise and type 2 diabetes. Diabetes Care. 2004; 27: 2518-2539.

5. Albright A. Diabetes. In: Ehrman JK, Gordon PM, Visich PS, Keteyian SJ, editors. Clinical Exercise Physiology. Champaign (IL): Human Kinetics; 2003. 133p.

6. Thompson WR, Gordon NF, Pescatello L. ACSM’s Guidelines for Exercise Testing and Prescription. 8th ed. Philiadelphia: Lippincott Williams & Wilkins; 2009.

7. Cefalu WT, Watson K. Intensive Glycemic Control and Cardiovascular Disease Observations From the ACCORD study. Diabetes. 2008;57:1163-1165.

8. Assessing Fitness to Drive, Austroads Ltd 2012, Fourth Edition 2012, National Transport Commission.


Search Terms

Diabetes, Hypoglycaemia, Hyperglycaemia, Exercise Physiology, Exercise, Type 1 Diabetes, Type 2 Diabetes, Blood Glucose Level, Blood Glucose Monitoring, BGL


Attachments

Attachment 1 – Nova StatStrip Blood Glucose/Ketone Skills Assessment Form

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.


Support8 of 11


https://www.diabetesaustralia.com.au/hypoglycaemia

CHHS18/117

Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval 19/03/2018 Complete Review Girish Talaulikar, ED

MedicineCHHS Policy Committee

This document supersedes the following: Document Number Document NameCHHS13/118 Exercise Physiology Department Management of hypoglycaemia and

hyperglycaemia in DMT1 and DMT2 patients


Support9 of 11


CHHS18/117

Attachment 1 – Nova StatStrip Blood Glucose/Ketone Skills Assessment Form

Participants Name Date

Work Location Assessor Name:

Correct technique, use and calibration of the Nova StatStrip Blood Glucose/Ketone meter is vital in the hospital setting to allow for correct management of people with Diabetes. It is expected clinical staff perform this assessment annually.

You will need to get 100% on this assessment to be credentialed in Blood Glucose/Ketone Monitoring. (Demonstration and Short Answer)

YES NO

Confirm, change and correct date/time on meter □ □Assembles correct equipment for Blood Glucose Monitoring □ □Assembles correct equipment for Blood Ketone Monitoring □ □Perform a Quality Control test, Level 1 on meter □ □Perform a Quality Control test, Level 3 on meter □ □Demonstrates correct use of lancet device □ □Obtain a suitable blood drop using correct technique □ □Apply blood correctly to strip □ □Reads and documents result □ □Discuss care and disposal of equipment and sharps □ □Aware of StatStrip eQA program for meters □ □

Questions

1) When should a Quality Control check be done on the Nova StatStrip Blood Glucose / Ketone meter?

______________________________________________________________

2) How many days are the glucose strips stable once opened?

____________________________________________________________

3) How many days are the ketone strips stable once opened?

_____________________________________________________________

4) How many days are the QC material stable once opened?

_____________________________________________________________

5) What is the measuring range of the StatStrip® glucose meter?

_____________________________________________________________

6) What is the measuring range of the StatStrip ketone meter?Doc Number Version Issued Review Date Area Responsible PageCHHS18/117 1 20/03/2018 01/04/2022 Medicine – Acute

Support10 of 11


CHHS18/117

______________________________________________________________

7) What should you do if a cBGL is < 4mmol/L?

______________________________________________________________

8) What should you do if a cBGL is > 15 mmol/L?

______________________________________________________________

9) If you had a patient in with Type 1 diabetes and had a cBGL > 15. What other test should you consider?

______________________________________________________________

10) What is the procedure if you suspect meter sensor failure?

______________________________________________________________

11) Why is quality control on the Nova StatStrip Blood Glucose/Ketone meter vital?

______________________________________________________________

Learning outcome:

I have assessed the candidate as: COMPETENT

NOT YET COMPETENT

I have discussed this assessment with the assessor and am satisfied with the conclusions.

Additional comments: _________________________________________________________________

Suggested future development options: __________________________________________________________________

CANDIDATE SIGNATURE: _______________________________________

ASSESSORS SIGNATURE: _____________________________________


Support11 of 11


exercise therapy – management of hypoglycaemia and ... · web viewclinician discretion is...

Documents