Implementation of glycemic control – problems and solutions

Introduction

Glycaemic control is another example of protocol-driven therapy in intensive care medicine to improve outcome in critically ill patients. While the advantage of this approach seems to be obvious, little is known about the problems of implementing such a protocol. The intention of this study was to evaluate problems of implementation and to develop strategies to overcome them.

Setting

A 16-bed surgical ICU of a university teaching hospital with 50 critical care nurses, about 30% in part-time employment.

Method

Over a 7-month period all patients staying longer than 48 hours in the ICU with hyperglycaemia (>150 mg%) on three consecutive measurements were included in the study. These patients were treated according to a protocol at the discretion of the attending nurse. On daily rounds and every 4–5 weeks supervision was performed, and the protocol was modified three times during this period according to staff comments. Further on, medical as well as nonmedical problems of implementation were analysed and discussed. Attitudes and perceived impeding aspects of the implementation process were recorded by means of a questionnaire.

Results

Since insulin sensitivity showed enormous variability, glycaemic control required a high nursing effort. Impeding aspects to titrate blood glucose into the target range were the absence of a nutritional protocol (high carbohydrate intake, despite inflammation/infection leading to hyperglycaemia that was difficult to control) and fear of hypoglycaemia (<60 mg%) leading to low-dose insulin with consecutive hyperglycaemia. Lack of communication (and therefore a loss of information) between critical care nurses and the intensivists and poor acceptance from physicians to leave this field of intensive care medicine to the nurses were additional factors that slowed the implementation process.

Conclusion

Implementation of protocol-driven medicine requires a high quality of information flow. The lack of linearity between blood glucose and insulin dose (variability of insulin sensitivity) required a sometimes intuitive (experienced) decision to titrate the insulin dose. The conflict of physicians with this new role of critical care nurses might be due to the lack of understanding of the evolution of the nursing profession.