Home, Community and Residential Care Services

Minister’s Directive:
Glucagon, Severe Hypoglycemia, and Unresponsive Hypoglycemia

Effective April 15, 2020

The Long-Term Care Homes Act, 2007 (Act) authorizes the Minister of Long-Term Care to issue operational or policy directives respecting long-term care homes where the Minister considers it in the public interest to do so. Every licensee shall carry out every operational or policy directive that applies to the long-term care home.

This directive applies to every long-term care home as defined under subsection 2(1) of the Act.

Definitions

All terms in this Directive have the same meaning as under the Act and Ontario Regulation 79/10 unless otherwise defined.

The following definitions apply for the purpose of this Directive:

Director means the person(s) appointed as the Director under the Act for the purposes of section 107 of Ontario Regulation 79/10.

Glucagon means a manufactured product that can be administered to raise glucose levels in the blood.

Severe hypoglycemia means an incident where a resident is found to have a blood glucose level less than 2.8 millimoles per litre (<2.8 mmol/L) and the resident is conscious.

Unresponsive hypoglycemia means an incident where a resident is found to have a blood glucose level less than 2.8 millimoles per litre (<2.8 mmol/L) and the resident is unconscious.

Effective April 15, 2020, I hereby issue the following Directive with respect to every long-term care home:

A.  Training

1. Every licensee of a long-term care home shall ensure that all direct care staff receive training on the requirements of this Directive.

B.  The use of glucagon

Documentation, review and analysis

2. (1) Every licensee of a long-term care home shall ensure that every use of glucagon involving a resident is,
(a) documented, together with a record of the immediate actions taken to assess and maintain the resident’s health; and
(b) reported to the resident, the resident’s substitute decision-maker, if any, the Director of Nursing and Personal Care, the Medical Director, the prescriber of the glucagon, the resident’s attending physician or the registered nurse in the extended class attending the resident and the pharmacy service provider.

(2) In addition to the requirement under clause 2(1)(a), the licensee shall ensure that,
(a) all uses of glucagon are reviewed and analyzed;
(b) corrective action is taken as necessary; and
(c) a written record is kept of everything required under clauses (a) and (b).

Quarterly evaluation

3. (1) Every licensee of a long-term care home shall ensure that an interdisciplinary team, which must include the Medical Director, the Administrator, the Director of Nursing and Personal Care and the pharmacy service provider meets at least quarterly to evaluate every written record under clause 2(2)(c) to identify utilization trends and patterns and to identify any changes necessary to improve the use of glucagon in the long-term care home in accordance with evidence-based practices and, if there are none, in accordance with prevailing practices.
(2) The licensee shall ensure that the changes identified in the quarterly evaluation are implemented.
(3) The licensee shall ensure that a written record is kept of the results of the quarterly evaluation and of any changes that were implemented.

Annual evaluation

4. (1)  Every licensee of a long-term care home shall ensure that an interdisciplinary team, which must include the Medical Director, the Administrator, the Director of Nursing and Personal Care and the pharmacy service provider meets annually to evaluate every written record in the previous year under subsection 3(3) to identify any changes necessary to improve the use of glucagon in the long-term care home in accordance with evidence-based practices and, if there are none, in accordance with prevailing practices.
(2) The licensee shall ensure that the changes identified in the annual evaluation are implemented.
(3) The licensee shall ensure that a written record is kept of the results of the annual evaluation and of any changes that were implemented.

C. Severe hypoglycemia or unresponsive hypoglycemia

Documentation, review and analysis

5. (1) Every licensee of a long-term care home shall ensure that every incident of severe hypoglycemia or unresponsive hypoglycemia involving a resident is,
(a) documented, together with a record of the immediate actions taken to assess and maintain the resident’s health; and
(b) reported to the resident, the resident’s substitute decision-maker, if any, the Director of Nursing and Personal Care, the Medical Director, the resident’s attending physician or the registered nurse in the extended class attending the resident and the pharmacy service provider.

(2) In addition to the requirement under clause 5(1)(a), the licensee shall ensure that,
(a) all incidents of severe hypoglycemia or unresponsive hypoglycemia are reviewed and analyzed;
(b) corrective action is taken as necessary; and
(c) a written record is kept of everything required under clauses (a) and (b).

Quarterly evaluation

6.  (1) Every licensee of a long-term care home shall ensure that an interdisciplinary team, which must include the Medical Director, the Administrator, the Director of Nursing and Personal Care and the pharmacy service provider meets at least quarterly to evaluate every written record under clause 5(2)(c) to identify utilization trends and patterns and to identify any changes necessary to improve the care and treatment of severe hypoglycemia or unresponsive hypoglycemia in accordance with evidence-based practices and, if there are none, in accordance with prevailing practices.
(2) The licensee shall ensure that the changes identified in the quarterly evaluation are implemented.
(3) The licensee shall ensure that a written record is kept of the results of the quarterly evaluation and of any changes that were implemented.

Annual evaluation

7. (1) Every licensee of a long-term care home shall ensure that an interdisciplinary team, which must include the Medical Director, the Administrator, the Director of Nursing and Personal Care and the pharmacy service provider meets annually to evaluate every written record in the previous year under subsection 6(3) to identify any changes necessary to improve the care and treatment of severe hypoglycemia or unresponsive hypoglycemia in accordance with evidence-based practices and, if there are none, in accordance with prevailing practices.
(2) The licensee shall ensure that the changes identified in the annual evaluation are implemented.
(3) The licensee shall ensure that a written record is kept of the results of the annual evaluation and of any changes that were implemented.

D.  Reporting Requirements

Reports to Director

8. (1) The licensee shall ensure that the Director is informed of the following incidents in the home no later than one business day after the occurrence of the incident, followed by the report required under subsection (3):

1. A resident who is administered glucagon which results in the resident being taken to a hospital.
2. A resident who experiences severe hypoglycemia or unresponsive hypoglycemia which results in the resident being taken to a hospital.

(2) Where a licensee is required to inform the Director of an incident under subsection (1), followed by the report required under subsection (3), the licensee shall use the Critical Incident Reporting System (CIR) to inform the Director using the category for paragraph 5 of subsection 107(3) of Ontario Regulation 79/10 until a new category is added to the system.
           
(3) A licensee who is required to inform the Director of an incident under subsection (1) shall, within 10 days of becoming aware of the incident, or sooner if required by the Director, make a report in writing to the Director setting out the following with respect to the incident:

1. A description of the incident, including the type of incident, the area or location of the incident, the date and time of the incident and the events leading up to the incident.
2. A description of the individuals involved in the incident, including,
   1. names of any residents involved in the incident,
   2. names of any staff members or other persons who were present at or discovered the incident, and
   3. names of staff members who responded or are responding to the incident.
3. Actions taken in response to the incident, including,
   1. what care was given or action taken as a result of the incident, and by whom,
   2. whether a physician or registered nurse in the extended class was contacted,
   3. what other authorities were contacted about the incident, if any,
   4. whether a family member, person of importance or a substitute decision-maker of the resident was contacted and the name of such person or persons, and
   5. the outcome or current status of the individual or individuals who were involved in the incident.
4. Analysis and follow-up action, including,
   1. the immediate actions that have been taken to prevent recurrence, and
   2. the long-term actions planned to correct the situation and prevent recurrence.

(4) The licensee shall ensure that the resident’s substitute decision-maker, if any, or any person designated by the substitute decision-maker and any other person designated by the resident are promptly notified in accordance with any instructions provided by the person or persons who are to be so notified.