Efficiency and safety of a standardized protocol for intravenous insulin therapy in ICU patients with neurovascular or head injury

Methodology for the analysis and comparison of protocols for glycaemic control in intensive care

RATIONALE, AIMS, AND OBJECTIVES

The practice of glycaemic control of critically ill patients admitted to intensive care units (ICUs) is guided by clinical management protocols, designed locally by the ICUs. These protocols differ significantly in their aims and methods. The aim of this study was to develop a standardized methodology for the systematic and objective analysis and comparison of protocols for glycaemic control implemented in any ICU.

METHOD

The protocols for glycaemic control implemented in seven ICUs of a UK-based ICU network were analysed using techniques of inductive content analysis, through an open coding process and the framework method. This involved the identification and classification of protocol instructions for glycaemic control, as well as of the processes and decisions pertaining to each of these instructions. These were used to develop a framework for the structured and systematic description and comparison of the protocols' contents, and to develop a technique for the protocols' graphic visualization.

RESULTS

The following elements were identified or developed: (1) 35 quantifiable variables and 11 non-quantifiable subjects that could be present in an ICU protocol for glycaemic control, to be used as a framework for the description and comparison of contents; (2) a technique for condensing a protocol into a single, comprehensive flowchart; (3) using these flowcharts, a method for assessing the complexity and comprehensiveness of the protocols.

CONCLUSIONS

The methodology developed in this study will allow for any future work analysing the contents of glycaemic control protocols to be carried out in a structured and standardized way. This may be done either as a standalone study, or as the essential first step in any investigation on the impact of new protocols. In turn, the methodology will facilitate the performance of regional, national, and international comparisons, demonstrating the usefulness of this study at a global scale.

The practice of glycaemic control in intensive care units: A multicentre survey of nursing and medical professionals

AIMS AND OBJECTIVES

To determine the views of nurses and physicians working in intensive care units (ICU) about the aims of glycaemic control and use of their protocols.

BACKGROUND

Evidence about the optimal aims and methods for glycaemic control in ICU is controversial, and current local protocols guiding practice differ between ICUs, both nationally and internationally. The views of professionals on glycaemic control can influence their practice.

DESIGN

Cross-sectional, multicentre, survey-based study.

METHODS

An online short survey was sent to all physicians and nurses of seven ICUs, including questions on effective glycaemic control, treatment of hypoglycaemia and deviations from protocols' instructions. STROBE reporting guidelines were followed.

RESULTS

Over half of the 40 respondents opined that a patient spending <75% admission time within the target glycaemic levels constituted poor glycaemic control. Professionals with more than 5 years of experience were more likely to rate a patient spending 50%-74% admission time within target glycaemic levels as poor than less experienced colleagues. Physicians were more likely to rate a patient spending <50% admission time within target as poor than nurses. There was general agreement on how professionals would rate most deviations from their protocols. Nurses were more likely to rate insulin infusions restarted late and incorrect dosage of rescue glucose as major deviations than physicians. Most professionals agreed on when they would treat hypoglycaemia.

CONCLUSIONS

When surveyed on various aspects of glycaemic control, ICU nurses and physicians often agreed, although there were certain areas of disagreement, in which their profession and level of experience seemed to play a role.

RELEVANCE TO CLINICAL PRACTICE

Differing views on glycaemic control amongst professionals may affect their practice and, thus, could lead to health inequalities. Clinical leads and the multidisciplinary ICU team should assess and, if necessary, address these differing opinions.

International multidisciplinary consensus conference on multimodality monitoring: ICU processes of care

There is an increased focus on evaluating processes of care, particularly in the high acuity and cost environment of intensive care. Evaluation of neurocritical-specific care and evidence-based protocol implementation are needed to effectively determine optimal processes of care and effect on patient outcomes. General quality measures to evaluate intensive care unit (ICU) processes of care have been proposed; however, applicability of these measures in neurocritical care populations has not been established. A comprehensive literature search was conducted for English language articles from 1990 to August 2013. A total of 1,061 articles were reviewed, with 145 meeting criteria for inclusion in this review. Care in specialized neurocritical care units or by neurocritical teams can have a positive impact on mortality, length of stay, and in some cases, functional outcome. Similarly, implementation of evidence-based protocol-directed care can enhance outcome in the neurocritical care population. There is significant evidence to support suggested quality indicators for the general ICU population, but limited research regarding specific use in neurocritical care. Quality indices for neurocritical care have been proposed; however, additional research is needed to further validate measures.

[Insulin infusion in intensive care: randomized controlled trial]

This randomized controlled trial compared the use of an intensive and conventional insulin protocol on clinical outcomes in patients with severe sepsis and septic shock, in the first 72 hours. It was conducted at a university hospital in the city of São Paulo. Patients (n=46) were allocated into two groups: intensive glycemic (blood glucose between 80-110mg/dl) and conventional (180-220mg/dl). The Student's t-test and chi-square test were used for data analysis. A statistically significant (p<0.001) difference was observed in mean glycemia, but there was no difference in the variables of mean minimum arterial pressure (p=0.06) or maximum (p=0.11), serum creatinine (p=0,33) or in mortality (p=0.11). Although there was no difference between the groups regarding mortality, hemodynamic instability in the conventional group was longer and the only deaths occurred in it.

Knowledge translation interventions for critically ill patients: a systematic review*

OBJECTIVE

We systematically reviewed ICU-based knowledge translation studies to assess the impact of knowledge translation interventions on processes and outcomes of care.

DATA SOURCES

We searched electronic databases (to July, 2010) without language restrictions and hand-searched reference lists of relevant studies and reviews.

STUDY SELECTION

Two reviewers independently identified randomized controlled trials and observational studies comparing any ICU-based knowledge translation intervention (e.g., protocols, guidelines, and audit and feedback) to management without a knowledge translation intervention. We focused on clinical topics that were addressed in greater than or equal to five studies.

DATA EXTRACTION

Pairs of reviewers abstracted data on the clinical topic, knowledge translation intervention(s), process of care measures, and patient outcomes. For each individual or combination of knowledge translation intervention(s) addressed in greater than or equal to three studies, we summarized each study using median risk ratio for dichotomous and standardized mean difference for continuous process measures. We used random-effects models. Anticipating a small number of randomized controlled trials, our primary meta-analyses included randomized controlled trials and observational studies. In separate sensitivity analyses, we excluded randomized controlled trials and collapsed protocols, guidelines, and bundles into one category of intervention. We conducted meta-analyses for clinical outcomes (ICU and hospital mortality, ventilator-associated pneumonia, duration of mechanical ventilation, and ICU length of stay) related to interventions that were associated with improvements in processes of care.

DATA SYNTHESIS

From 11,742 publications, we included 119 investigations (seven randomized controlled trials, 112 observational studies) on nine clinical topics. Interventions that included protocols with or without education improved continuous process measures (seven observational studies and one randomized controlled trial; standardized mean difference [95% CI]: 0.26 [0.1, 0.42]; p = 0.001 and four observational studies and one randomized controlled trial; 0.83 [0.37, 1.29]; p = 0.0004, respectively). Heterogeneity among studies within topics ranged from low to extreme. The exclusion of randomized controlled trials did not change our results. Single-intervention and lower-quality studies had higher standardized mean differences compared to multiple-intervention and higher-quality studies (p = 0.013 and 0.016, respectively). There were no associated improvements in clinical outcomes.

CONCLUSIONS

Knowledge translation interventions in the ICU that include protocols with or without education are associated with the greatest improvements in processes of critical care.

Quality Improvement Project: analysis of efficiency of current order set for the diagnostic workup used to evaluate neurogenic stress myocardium in aneurysmal subarachnoid hemorrhage

PURPOSE

To evaluate patterns of utilization of the aneurysmal subarachnoid hemorrhage (aSAH) protocol order set for neurogenic stress myocardium (NSM).

DATA SOURCES

Retrospective chart review.

CONCLUSIONS

The results of this study demonstrate that protocol order sets can be prone to omissions, variations in practice, and delays.

IMPLICATIONS FOR PRACTICE

Education and implementation of an intervening compliance monitor are essential to improve utilization and correctness in use of the aSAH protocol order set for NSM. Advance practice nurses (APNs) or nursing staff could provide this service. This would improve teamwork, improve efficiency of care delivery and utilization of resources, promote leadership and improved outcomes, and promote relationship-based care.

Treating hyperglycemia in neurocritical patients: benefits and perils

There is growing debate over the value of intensive insulin therapy (IIT) in critically ill patients. Available trials have been performed in general medical or surgical intensive care units, and the results may not be directly applicable to patients with severe acute brain disease because these patients may have heightened susceptibility to hyperglycemia (HyperG) and hypoglycemia. Our objective was to review the pathophysiology and effects of HyperG and hypoglycemia in neurocritical patients and to analyze the potential role of IIT in this population. Source data were obtained from a PubMed search of the medical literature combining the terms HyperG, hypoglycemia, insulin, stroke, intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), traumatic brain injury (TBI), spinal cord injury (SCI), and related diagnoses. Brain metabolism is highly dependent on constant supply of glucose. As a consequence, the acutely injured brain is particularly sensitive to hypoglycemia, which can induce a state of energy failure (metabolic crisis). Meanwhile, neurocritical patients have a high prevalence of HyperG, and its occurrence is associated with poor outcome after acute ischemic stroke, ICH, SAH, and TBI. It is unclear whether this association is due to direct detrimental effects exerted by HyperG or simply represents a marker of severe brain injury. Insulin has been shown to have various potentially pleiotropic neuroprotective properties in experimental models. However, the safety and efficacy of IIT in patients with critical brain disease have not been well studied. Available results do not support the use of IIT to maintain strict normoglycemia in this population. Patients with critical brain disease should have frequent glucose monitoring because severe HyperG and even modest hypoglycemia may be detrimental. Careful use of insulin infusion protocols appears advisable, but maintenance of strict normoglycemia cannot be recommended. Rigorous studies must be conducted to assess the value of insulin therapy and to determine the optimal blood glucose targets in patients with the most common acute vascular and traumatic brain insults.