Listening to the Evidence: CKHS Updates Glycemic Control Protocol for Critical Care Patients
Numerous studies have shown that improving glycemic control results in better outcomes for critically ill patients, including fewer blood transfusions, less renal failure, fewer days on ventilator and shorter stays. In March 2005, as part of the VHA Transformation of the Intensive Care Unit initiative, Crozer-Keystone set a goal of tightening glycemic control by maintaining 75 percent of ICU patients within the blood glucose range of 70 to 120 mg per deciliter. The system’s critical care units were very successful in achieving that goal using finely tuned protocols developed by multidisciplinary teams at Crozer-Chester Medical Center, Delaware County Memorial Hospital and Taylor Hospital.
This year, the CKHS Glycemic Control Committee met to review the results of a new glucose control study and to evaluate the system’s glucose control goals and protocols in light of the latest evidence in the literature. The NICE-SUGAR* study, published in The New England Journal of Medicine (March 26, 2009), compared the effectiveness of intensive versus conventional glucose control in more than 6,100 critically ill patients in an international, randomized trial. The study concluded that a blood glucose target of 180 mg or less per deciliter results in better patient outcomes than a target of 81 to 108 mg per deciliter and resulted in less hypoglycemic events.
After careful evaluation of the study, the CKHS Glycemic Control Committee decided to change the system’s glucose control goals for critically ill patients on a ventilator to reflect this latest evidence. In May 2009, the committee set a goal of maintaining 70 percent of these patients within a new blood glucose target range of 100 to 140 mg per deciliter.
“It is important to manage glucose in critically ill patients,” notes Patricia LaPorta, RN, BSN, MS, CCRN, BC, critical care clinical nurse educator at DCMH and a member of the committee. “However, the study showed that a higher target range was preferable, and our physicians and nursing staff embraced the idea, particularly since it decreases concerns about hypoglycemia occurring at the lower target range.”
The system’s multidisciplinary glycemic control committee includes representatives from the intensive care units, Endocrinology, intensivists, Pharmacy, Quality and Patient Safety, Evidence-Based Medicine and nursing staffs. The critical care nurse managing these patients on a daily basis identified several improvements, which have been incorporated into the revised protocol. Pharmacists were instrumental in implementation of the new insulin infusion protocol by re-creating the glycemic flow sheets to reflect the new blood glucose target range. The flow sheets, used in all CKHS intensive care units, are based on the column system that uses a narrower range of blood glucose values in each column to determine the appropriate insulin dosage. This allows the nursing staff more flexibility in increasing or decreasing the dosages in response to changes in the patient’s blood sugar.
The updated protocol was implemented system wide during the summer of 2009. “Currently, our glycemic control is still excellent in the ICUs with limited hypoglycemia,” says LaPorta. “Most months, we are exceeding our goal, with 80 to 85 percent of our critically ill patients being maintained within the 100 to 140 mg/Dl range.”
*The Normoglycemia in Intensive Care Evaluation – Survival Using Glucose Algorithm Regulation (NICE-SUGAR) Study is a collaboration of the Australian and New Zealand Intensive Care Society Clinical Trials Group, the George Institute for International Health (University of Sydney), the Canadian Critical Care Trials Group, and the Vancouver Coastal Health Research Institute (University of British Columbia.)
Glycemic Control Protocol in Brief:
- Maintain critically ill patients on a ventilator in a blood glucose target range of 100 to 140 mg per deciliter.
- The ICU nursing staff manages patients by monitoring their blood glucose with hourly finger stick tests. This enables the nursing staff to respond to blood glucose changes and adjust the continuous drip insulin dosage to maintain glucose levels within target range.
- The nursing staff adjusts the insulin dosage based on blood glucose changes, not just blood glucose value.
- Nurses use a column system chart with narrower ranges of blood glucose values in each column to determine the appropriate insulin dosage.
- The majority of antibiotics are administered to patients in normal saline solution instead of dextrose.
- The nursing staff initiated a change to variable depth lancets for hourly finger stick tests to reduce discomfort for the patients.
- The clinical pharmacist rounds on ICU patients every day.
- The ICU nursing staff continuously evaluates the protocol and recommends changes to the multidisciplinary team