Innovative solutions: development and implementation of a tight blood glucose management protocol: one community hospital's experience.
ABSTRACT Blood glucose monitoring and control are an important component of nursing care for the critically ill patient. This article discusses the efforts of one community hospital in the development of a tight blood glucose management protocol for cardiopulmonary bypass patients.
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ABSTRACT: The benefits and harms of intensive insulin therapy (IIT) titrated to strict glycemic targets in hospitalized patients remain uncertain. To evaluate the benefits and harms of IIT in hospitalized patients. MEDLINE and Cochrane Database of Systematic Reviews from 1950 to January 2010, reference lists, experts, and unpublished sources. English-language randomized, controlled trials comparing protocols titrated to strict or less strict glycemic targets. Two reviewers independently abstracted data from each study on sample, setting, glycemic control interventions, glycemic targets, mean glucose levels achieved, and outcomes. Results were grouped by patient population or setting. A random-effects model was used to combine trial data on short-term mortality (≤28 days), long-term mortality (90 or 180 days), infection, length of stay, and hypoglycemia. The Grading of Recommendations Assessment, Development, and Evaluation system was used to rate the overall body of evidence for each outcome. In a meta-analysis of 21 trials in intensive care unit, perioperative care, myocardial infarction, and stroke or brain injury settings, IIT did not affect short-term mortality (relative risk, 1.00 [95% CI, 0.94 to 1.07]). No consistent evidence showed that IIT reduced long-term mortality, infection rates, length of stay, or the need for renal replacement therapy. No evidence of benefit from IIT was reported in any hospital setting, although the best evidence for lack of benefit was in intensive care unit settings. Data combined from 10 trials showed that IIT was associated with a high risk for severe hypoglycemia (relative risk, 6.00 [CI, 4.06 to 8.87]; P < 0.001). Risk for IIT-associated hypoglycemia was increased in all hospital settings. Methodological shortcomings and inconsistencies limit the data in perioperative care, myocardial infarction, and stroke or brain injury settings. Differences in insulin protocols and patient and hospital characteristics may affect generalizability across treatment settings. No consistent evidence demonstrates that IIT targeted to strict glycemic control compared with less strict glycemic control improves health outcomes in hospitalized patients. Furthermore, IIT is associated with an increased risk for severe hypoglycemia. U.S. Department of Veterans Affairs Health Services Research and Development Service.Annals of internal medicine 02/2011; 154(4):268-82. DOI:10.1059/0003-4819-154-4-201102150-00008 · 16.10 Impact Factor
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ABSTRACT: As a quality improvement initiative, nurses in a general critical-care unit at a Midwest hospital constructed a plan for interventional hygiene. A nationally recognized nursing expert inspired the theoretical framework used as a basis for the initiative. A critical-care nursing clinical excellence team examined the current state and developed, implemented, and evaluated the interventional hygiene plan. Goals included standardizing bathing procedures and use of beds and reducing nosocomial infections and incontinence-associated dermatitis in critically ill adults. During the evaluation period, incidence of unit-acquired methicillin-resistant Staphylococcus aureus and incontinence-associated dermatitis decreased. Nurses reported favorable reviews for new skin care products and decreased nursing time associated with bathing.Dimensions of critical care nursing: DCCN 01/2011; 30(3):169-76. DOI:10.1097/DCC.0b013e31820d25b1
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ABSTRACT: OBJECTIVE:: To evaluate the literature and identify important aspects of insulin therapy that facilitate safe and effective infusion therapy for a defined glycemic end point. METHODS:: Where available, the literature was evaluated using Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology to assess the impact of insulin infusions on outcome for general intensive care unit patients and those in specific subsets of neurologic injury, traumatic injury, and cardiovascular surgery. Elements that contribute to safe and effective insulin infusion therapy were determined through literature review and expert opinion. The majority of the literature supporting the use of insulin infusion therapy for critically ill patients lacks adequate strength to support more than weak recommendations, termed suggestions, such that the difference between desirable and undesirable effect of a given intervention is not always clear. RECOMMENDATIONS:: The article is focused on a suggested glycemic control end point such that a blood glucose ≥150 mg/dL triggers interventions to maintain blood glucose below that level and absolutely <180 mg/dL. There is a slight reduction in mortality with this treatment end point for general intensive care unit patients and reductions in morbidity for perioperative patients, postoperative cardiac surgery patients, post-traumatic injury patients, and neurologic injury patients. We suggest that the insulin regimen and monitoring system be designed to avoid and detect hypoglycemia (blood glucose ≤70 mg/dL) and to minimize glycemic variability.Important processes of care for insulin therapy include use of a reliable insulin infusion protocol, frequent blood glucose monitoring, and avoidance of finger-stick glucose testing through the use of arterial or venous glucose samples. The essential components of an insulin infusion system include use of a validated insulin titration program, availability of appropriate staffing resources, accurate monitoring technology, and standardized approaches to infusion preparation, provision of consistent carbohydrate calories and nutritional support, and dextrose replacement for hypoglycemia prevention and treatment. Quality improvement of glycemic management programs should include analysis of hypoglycemia rates, run charts of glucose values <150 and 180 mg/dL. The literature is inadequate to support recommendations regarding glycemic control in pediatric patients. CONCLUSIONS:: While the benefits of tight glycemic control have not been definitive, there are patients who will receive insulin infusion therapy, and the suggestions in this article provide the structure for safe and effective use of this therapy.Critical care medicine 12/2012; 40(12):3251-3276. DOI:10.1097/CCM.0b013e3182653269 · 6.15 Impact Factor