Introducing intensive insulin therapy: the nursing perspective

Nurse-Directed Blood Glucose Management in a Medical Intensive Care Unit

BACKGROUND

Insulin-delivery algorithms for achieving glycemic control in the intensive care unit require frequent checks of blood glucose level and thus increase nursing workload. Hypoglycemia is a serious complication associated with intensive insulin therapy.

OBJECTIVES

To evaluate a nurse-directed protocol for blood glucose management that allows individualized insulin delivery within a predefined blood glucose corridor, intended to avoid hypoglycemia while maintaining adequate control of blood glucose level without increasing nursing workload.

METHODS

A nurse-directed protocol for blood glucose management was developed by an interprofessional team, and the protocol's performance was investigated in 175 patients compared with 384 historical controls.

RESULTS

With the nurse-directed protocol, hypoglycemia incidents declined significantly (31% vs 12%, P < .001), and minimum blood glucose levels increased significantly (80 mg/dL vs 93 mg/dL, P < .001). Mean and maximum blood glucose levels, the proportion of glucose readings within the target range (31% vs 26%, P = .06), and the number of blood glucose checks (59 vs 58, P = .85) remained unchanged with use of the protocol.

CONCLUSION

Implementation of the nurse-directed protocol for blood glucose management did not increase nursing workload but reduced hypoglycemia incidents significantly while maintaining adequate glycemic control.

Glycaemic variability in patients with severe sepsis or septic shock admitted to an Intensive Care Unit

BACKGROUND

Sepsis is associated with morbidity and mortality, which implies high costs to the global health system. Metabolic alterations that increase glycaemia and glycaemic variability occur during sepsis.

OBJECTIVE

To verify mean body glucose levels and glycaemic variability in Intensive Care Unit (ICU) patients with severe sepsis or septic shock.

METHOD

Retrospective and exploratory study that involved collection of patients' sociodemographic and clinical data and calculation of severity scores. Glycaemia measurements helped to determine glycaemic variability through standard deviation and mean amplitude of glycaemic excursions.

RESULTS

Analysis of 116 medical charts and 6730 glycaemia measurements revealed that the majority of patients were male and aged over 60 years. Surgical treatment was the main reason for ICU admission. High blood pressure and diabetes mellitus were the most usual comorbidities. Patients that died during the ICU stay presented the highest SOFA scores and mean glycaemia; they also experienced more hypoglycaemia events. Patients with diabetes had higher mean glycaemia, evaluated through standard deviation and mean amplitude of glycaemia excursions.

CONCLUSION

Organic impairment at ICU admission may underlie glycaemic variability and lead to a less favourable outcome. High glycaemic variability in patients with diabetes indicates that monitoring of these individuals is crucial to ensure better outcomes.

Planned change or emergent change implementation approach and nurses' professional clinical autonomy

BACKGROUND

Nurses' clinical autonomy is considered important for patients' outcome and influenced by the implementation approach of innovations. Emergent change approach with participation in the implementation process is thought to increase clinical autonomy. Planned change approach without this participation is thought not to increase clinical autonomy. Evidence of these effects on clinical autonomy is however limited.

AIMS AND OBJECTIVES

To examine the changes in clinical autonomy and in personal norms and values for a planned change and emergent change implementation of an innovation, e.g. intensive insulin therapy.

DESIGN

Prospective comparative study with two geographically separated nurses' teams on one intensive care unit (ICU), randomly assigned to the experimental conditions.

METHODS

Data were collected from March 2008 to January 2009. Pre-existing differences in perception of team and innovation characteristics were excluded using instruments based on the innovation contingency model. The Nursing Activity Scale was used to measure clinical autonomy. The Personal Values and Norms instrument was used to assess orientation towards nursing activities and the Team Learning Processes instrument to assess learning as a team.

RESULTS

Pre-implementation the measurements did not differ. Post-implementation, clinical autonomy was increased in the emergent change team and decreased in the planned change team. The Personal Values and Norms instrument showed in the emergent change team a decreased hierarchic score and increased developmental and rational scores. In the planned change team the hierarchical and group scores were increased. Learning as a team did not differ between the teams.

CONCLUSIONS

In both teams there was a change in clinical autonomy and orientation towards nursing activities, in line with the experimental conditions. Emergent change implementation resulted in more clinical autonomy than planned change implementation.

RELEVANCE TO CLINICAL PRACTICE

If an innovation requires the nurses to make their own clinical decisions, an emergent change implementation should help to establish this clinical autonomy.

Assessment of nursing perceptions of three insulin protocols for blood glucose control in critically ill patients

OBJECTIVE

To evaluate nurses' perception regarding three different blood glucose control protocols for critically ill patients.

METHODS

As part of a randomized trial comparing three blood glucose control protocols in critically ill patients (Computer-Assisted Insulin Protocol, Leuven Protocol, and conventional treatment), all nurses participating in the study were asked to fill in a questionnaire to assess their perceptions of efficacy, complexity, feasibility, and safety (as to the occurrence of hypoglycemic episodes), an to indicate which protocol they would like to see adopted as the standard one in the Intensive Care Unit they worked.

RESULTS

Sixty nurses answered the questionnaires. Computer-Assisted Insulin Protocol was considered the most efficient protocol to maintain blood glucose levels within the target range by 58% of the nurses, compared to 22% for Leuven Protocol (p<0.001) and 40% for conventional treatment (p=0.04). Computer-Assisted Insulin Protocol was considered easier to use than Leuven Protocol (p<0.001) and as easy as conventional treatment (p=0.78). Out of the nurses, 37% considered Computer-Assisted Insulin Protocol more feasible than Leuven Protocol and conventional treatment. A total of 51% of nurses chose Leuven Protocol as the protocol more often associated with hypoglycemia, while 27% chose Computer-Assisted Insulin Protocol and 8% conventional treatment. Finally, 56% of the nurses selected Computer-Assisted Insulin Protocol as the protocol they would like to see adopted as the standard one in the Intensive Care Unit they were based, as compared to 22% that selected Leuven Protocol and 15% that selected conventional treatment.

CONCLUSION

Computer-Assisted Insulin Protocol was considered more efficacious, easier to use and safer than Leuven Protocol by nurses. The complexity and feasibility of Computer-Assisted Insulin Protocol were considered similar to conventional treatment. Most nurses chose of Computer-Assisted Insulin Protocol as the protocol they would like to see adopted in their Intensive Care Units.

Improving glycemic control with the adjunct use of a data management software program

BACKGROUND

Published studies have supported the implementation of tight glucose control (TGC) programs to improve patient outcomes and reduce mortality rates. However, measuring a program's efficiency is challenging, because of a lack of systems that capture data, allow access to data, and support analysis and interpretation in a near prospective time frame. We hypothesized that providing clinicians access to real-time blood glucose (BG) results reports could improve the efficacy of our TGC program.

METHODS

We performed a retrospective review of BG data during a 12-month period in a surgical trauma intensive care unit at a level I trauma center. A unit-specific insulin algorithm was used throughout the study. We compared BG values before and after the implementation of a data management software program that allowed clinicians access to real-time BG results reports. Reports were run daily and weekly to monitor the unit's TGC program.

RESULTS

A total of 70 616 BG values from 1044 patients were analyzed. An overall decrease was observed in the BG level mean, from 121 mg/dL to 112 mg/dL (P < .001), as well as a decrease in the aggregated mean across patients, from 132 mg/dL to 119 mg/dL (P < .001), after implementation of the software. The percentage of values within the target range of 80 to 110 mg/dL increased from 38.9% to 50.4% (P < .001). The percentage of BG values less than 70 increased from 2.7% to 3.4% (P < .001). However, the percentage of severe hypoglyce-mic episodes (≤ 40 mg/dL) remained unchanged.

CONCLUSIONS

Access to real-time aggregated BG data reports through the use of a data management software program improved the efficacy of our TGC program.

How to weigh the current evidence for clinical practice

This article presents a template for judging trials of tight glucose control in critically ill patients. It reviews threats to both internal validity and generalisability using examples from the current literature. When judging internal validity, it is important to consider factors specific to trials of glucose control (particularly the methods of glucose control, measurement and reporting) in addition to factors common to all randomised controlled trials (such as treatment allocation, losses to follow-up and protocol violations). Judging generalisability requires the identification of differences between the trial population and the population for whom the intervention is being considered. These may relate to the setting, the patients or the practical delivery of tight glucose control or other interventions. Once identified, a judgement must be made for each difference of whether it is likely to modify the effect of tight glucose control.

Nursing involvement improves compliance with tight blood glucose control in the trauma ICU: a prospective observational study

INTRODUCTION

The importance of tight glycaemic control has gained acceptance over the last 5 years as a critical component of routine intensive care unit (ICU) measures. In an environment already strained for resources and staffing, however, effective strategies providing for increased input and responsibility of bedside nursing personnel are paramount to successful implementation.

HYPOTHESIS

Increasing input and responsibilities of ICU nursing staff in tight glycaemic control policies improves glucose control in the trauma ICU.

METHODS

After Institutional Review Board approval, we conducted a prospective "before-after" trial examining the effect of nursing education and input on outcome of a tight (goal 80-120 mg/dL) glycaemic control protocol. After a three month assessment of compliance with a previously physician-developed protocol, an educational in-service was conducted for all trauma ICU nursing staff. Nursing staff were then asked to provide input on the development of a new protocol using multiple-choice ballots to define 7 components of protocol criteria. Using nursing input, we developed and implemented a new glycaemic protocol that shifted much of the responsibility for initiation and subsequent adjustment of insulin infusion to the bedside nurse, allowing them to more liberally utilise their bedside clinical judgment and knowledge of the specific patient.

RESULTS

Nursing input on seven factors of protocol criteria did not differ significantly from the previously existing protocol, except with reference to nursing desire for increased responsibility in the implementation and maintenance of tight glycaemic control. After three months implementation of a new protocol developed utilising nursing input, both mean blood glucose levels achieved (137.8 mg/dL vs. 128.2mg/dL, p=0.028) and time to first hourly blood glucose within goal range (<120 mg/dL) was improved (36 h vs. 9h). The number of hypoglycaemic (BS <60) episodes increased slightly after revision (1 event vs. 5 event), with no hypoglycaemic seizures or coma occurring during either period.

CONCLUSION

Nursing input and increased responsibility improved the results of a tight glycaemic control in our trauma ICU. Increasing nursing input in the development and implementation of a tight glycaemic policies can result in safe and effective improved glucose control in the trauma ICU.

Designing and implementing insulin infusion protocols and order sets

Influential trials and guidelines supporting the value of glucose control in hospital settings, particularly in the intensive care and postoperative settings, has led to the widespread adoption of intravenous infusions of human regular insulin. As groups have attempted to study the outcomes or to explore improved methods for improved glucose control, a number of insulin infusion protocols (IIPs) have been reported and validated. Now, many institutions are attempting to translate this experience into clinical practice in a systematic manner. The intent of this discussion is to highlight the authors' practical view of best practices in development and use of IIPs. As the implementation of IIPs has progressed, it has become apparent that this is not a simple process. It requires a carefully planned, inclusive, and continuous effort striving to attain effective glucose control while avoiding severe hypoglycemia. Whereas there are limitations in the literature comparing the IIPs, we identify design elements and implementation methods that increase the chances for staff acceptance and safe attainment of glycemic goals. Most importantly, this must be a team effort with attention to the numerous potential pitfalls that can disrupt the process and place patients at risk. In many cases, it is best to start more conservatively and methodically intensify the protocol. Continuous assessment of protocol errors, adverse events, staff satisfaction, and outcomes is vital to overall success.

A randomized study in diabetic patients undergoing cardiac surgery comparing computer-guided glucose management with a standard sliding scale protocol

OBJECTIVE

The aim of this study was to compare a standard insulin protocol with a computer-guided glucose management system to determine which method achieves tighter glucose control.

DESIGN

A prospective, randomized trial.

SETTING

A cardiothoracic intensive care unit (ICU) in a large academic medical center.

PARTICIPANTS

Forty patients with diabetes mellitus who were scheduled for cardiac surgery.

INTERVENTIONS

After induction of anesthesia and for the first 9 hours in the ICU, each subject received a standardized infusion of a 10% glucose solution at a rate of 1.0 mL/kg/h (ideal body weight). The subjects were then randomized to have their glucose controlled by either a paper-based insulin protocol or by a computer-guided glucose management system (CG). The desired range for blood glucose was set between 90 and 150 mg/dL.

MEASUREMENTS AND MAIN RESULTS

There were no differences between groups in baseline characteristics. Patients in the CG group spent more time in the desired range during both the intraoperative phase (49% v 27%, p = 0.001) and the ICU phase (84% v 60%, p < 0.0001). There were no statistical differences between groups in the number of hypoglycemia episodes.

CONCLUSIONS

The computer-guided glucose management system achieved tighter blood glucose control than a standard paper-based protocol in diabetic patients undergoing cardiac surgery. However, the low proportion of blood glucose recordings within the desired range in both groups during the intraoperative period reflects the challenges associated with achieving normoglycemia during cardiac surgery.

Parenteral glucose and glucose control in the critically ill: a kinetic appraisal

BACKGROUND

We investigated the influence of parenteral glucose infusion on insulin-driven tight glucose control (4.4-6.1 mmol/liter) in the critically ill by appraising kinetic characteristics of the glucoregulatory system.

METHODS

Turnover characteristics of the glucoregulatory system associated with constant 0, 1.2, and 2.4 mg/kg/min parenteral glucose infusion were obtained by literature review and mass-balance calculations.

RESULTS

Without parenteral glucose infusion, the achievement of tight glucose control is hampered by long time delays with an anticipated glucose equilibration half-time (T((1/2))) of 185 min. The constant parenteral glucose infusions of 1.2 and 2.4 mg/kg/min reduce T((1/2)) to 80 and 40 min, respectively. This follows on from the accelerated glucose turnover brought about by the insulin-modulated glucose uptake, which increases in response to increasing exogenous insulin required to achieve tight glucose control. However, large variations exist among glucose turnover characteristics in the critically ill.

CONCLUSIONS

The constant parenteral glucose infusion greater or equal to 2.4 mg/kg/min is expected to simplify the achievement of tight glucose control by reducing system delays and may facilitate the development of more intuitive, efficacious, and safer insulin-titration guidelines.