I

R

Ics

G

a

Cb

c

0d

ntensive and Critical Care Nursing (2009) 25, 294—305

avai lab le at www.sc iencedi rec t .com

journa l homepage: www.e lsev ier .com/ iccn

EVIEW

s nurse-managed blood glucose control in criticalare as safe and effective as the traditional slidingcale method?

ary Adamsa,∗, Jo Hunterb, Jane Langleyc

Insulin Diabetes Experimental Research Group, Faculty of Medicine and Health Sciences, The University of Nottingham,lifton Boulevard, Nottingham NG7 2UH, United KingdomIntensive Care, Nottingham University Hospitals NHS Trust, QMC campus, Derby Road, Nottingham NG7 2UH, United KingdomIntensive Care, United Lincolnshire ULH Trust, Greetwell Road, Lincoln, Lincolnshire LN2 5QY, United Kingdom

Accepted 19 September 2009

KEYWORDSCritical care;Nurse-managed;Blood glucose;Sliding scale

SummaryBackground: Hyperglycaemia occurs in a substantial proportion of critically ill patients. Recentstudies have demonstrated that controlling blood glucose in critically ill patients can improveoutcomes (Boord et al., 2001). Traditionally, blood glucose is controlled by the sliding scalemethod. A pre-defined dose of intravenous insulin is infused for each glucose level. Revisionsto the prescription are frequently necessary when it is ineffective. The objective of this reviewis to assess the effectiveness, safety and feasibility of nurse-managed protocols that requireminimal physician input.Methods: An electronic search was performed on the Medline, CINAHL and EMBASE databasesfrom 1996 to 2008. The objective of this work was to assess nurse-managed glycaemic controlin critically ill patients. The target blood glucose was required to be less than 8.3 mmol/L.Results: Fourteen papers met the inclusion criteria. Eight studies compared their protocol tothe previous method of glucose control (Table 1). In all cases there was an improvement. Timeto reach target was less and time spent within target range was greater. All but one studyreduced episodes of hypoglycaemia with the new protocol. Six studies developed their protocol

as a quality improvement project and did not use a control group (Table 2).Conclusion: An insulin infusion protocol (IIP) that uses the last two blood glucose levels inorder to determine the new infusion rate is better at maintaining glycaemic control than thetraditional sliding scale method. A protocol that allows a nurse to commence and maintain theinfusion is as safe and more effective than the traditional sliding scale method.© 2009 Elsevier Ltd. All rights re

∗ Corresponding author. Tel.: +44 0115 8230901; fax: +44 0115 8230999E-mail address: Gary.Adams@nottingham.ac.uk (G. Adams).

964-3397/$ — see front matter © 2009 Elsevier Ltd. All rights reserved.oi:10.1016/j.iccn.2009.09.002

served.

.

M

D1Dbcqhd

agMrt

emigp(plplt

de

R

Tptoc(8t

crioIt

S

Ati

Nurse-managed glycaemic control in critically ill patients

Introduction

Any type of critical illness results in stress hyperglycaemiaas a result of insulin resistance and glucose intolerance(McCowen et al., 2001). Illness or trauma increases glu-cose production in the liver with continued gluconeogenesisdespite hyperglycaemia and high levels of insulin release(Van Den Berghe, 2004).

There is also increased release of the stress hormone cor-tisol and catecholamines, growth hormone and glucagon.These cause an increase in gluconeogenesis, glycogenolysis,lipolysis and proteolysis (Dilkhush et al., 2005). In diabeticpatients, hyperglycaemia is higher still, as diabetics can-not increase insulin production to counteract the effect ofthe stress hormones (Vasa and Molitch, 2001). Most of thesepatients are also receiving enteral or parenteral nutrition,which can further contribute to increased glucose levels(Carlson, 2001). Sympathomimetics and corticosteroids canalso lead to hyperglycaemia by increasing insulin resistancein the peripheral tissues (Montori et al., 2002),

The resulting hyperglycaemia is associated with manycomplications including infection, increased duration ofmechanical ventilation, increased intensive care unit (ICU)stay and cost (Scheuren et al., 2006) and renal failure, bloodtransfusions and polyneuropathy (Van Den Berghe et al.,2001).

Since the publication of a large prospective randomisedcontrolled study looking at intensive insulin therapy in criti-cally ill patients (Van Den Berghe et al., 2001), tight glucosecontrol has been an important part of evidence based criti-cal care medicine. The Van Den Berghe study included 1548surgical patients, this demonstrated a reduction in mortal-ity from 8% with conventional insulin treatment to 4.6% withintensive insulin therapy. The main benefit was in patientsthat stayed in intensive care for more than five days andin patients with multi-organ failure and sepsis. The studyalso found a reduction in bloodstream infections of 46%,acute renal failure requiring dialysis or filtration by 41%,blood transfusions by 50% and critical illness polyneuropa-thy by 44%. Van Den Berghe et al. (2006) also showed animprovement in mortality in critically ill medical patientstreated with tight glycaemic control and reduced morbid-ity if they stayed in intensive care for more than threedays. Reduced morbidity has also been shown in a mixedmedical—surgical ICU (Krinsley, 2004) and is included inthe surviving sepsis guidelines (Institute for HealthcareImprovement, 2005).

The process of achieving tight glucose control is not riskfree. The need for frequent and accurate blood glucose mea-surement and the potential for prolonged and unrecognisedhypoglycaemia are of concern (Ball et al., 2007). Much ofthe care given to intensive care patients is a result of tra-dition or clinicians preference (Woodrow, 2001). However,the advent of clinical governance (Department of Health,1997) means that practice is changing in line with bestavailable evidence. Health service practitioners are ableto change practice within their own areas of expertise

such as the advent of nurse-led insulin scales. The pur-pose of this literature review is to critically appraise theevidence available for this approach and consider it as anoption to improve glycaemic control within adult intensivecare.

csapw

295

ethods

ue to the growing volume of published research (Booth,996), the variable quality of research (Rosenberg andonald, 1995) and the pressure to implement evidence-ased practice (Smith et al., 2004), research reviews, whichompare the findings of numerous studies and evaluate theuality of the research are increasingly being used in theealthcare environment to formulate policy and influenceecisions.

An extended literature review was the chosen method tonalyse the vast quantities of literature now available onlycaemic control in critical care. The CINAHL, EMBASE andedline databases were searched and the reference lists of

elevant studies reviewed to locate any studies missed onhe original search.

The full texts of identified studies were examined tonsure that they met the inclusion criteria and to assess theirethodological quality. In terms of inclusion criteria, stud-

es were included if (1) the objective was nurse-managedlycaemic control in adult critical care patients, (2) a newrotocol was developed or an existing protocol updated,3) an example of the protocol was included, (4) they wereublished after 1997, and (5) the target blood glucose wasess than 8.3 mmol/L. Studies in children, non-critical careatients and pregnant women were excluded as were thoseooking at glucose, insulin and potassium (GIK) infusions andhose with a blood glucose target range above 8 mmol/L.

Limitations of this review include only articles in Englishue to the difficulties of translating, consequently some rel-vant articles may have been missed.

esults and discussion

he search results identified one hundred eighty-eightotentially relevant papers, of these twenty-five werehought to be relevant. Detailed inspection excluded ninef these because of not including an example of the proto-ol, (1) primarily looking at glucose, insulin and potassiumGIK) infusions and (2) an upper target blood glucose abovemmol/L. A total of fourteen papers met the inclusion cri-

eria and were entered into the review.In eight of the fourteen studies, the new protocol was

ompared to the previous method of glucose control. In theemaining six studies the protocol was developed as a qual-ty improvement project and did not use a control group. Allf these studies can be categorised into surgical, cardiac,CU/Coronary Care Unit (CCU), trauma and mixed interven-ion themes (see Tables 1 and 2).

urgical interventions

study carried out by Taylor et al. (2006) (Study 8) aimedo determine the efficacy and safety of a nurse-drivennsulin infusion protocol to lower blood glucose in criti-

al care. This cohort study evaluated the protocol in threetages. In the pre-intervention phase, 71 patients received

physician-initiated insulin infusion without a developedrotocol (phase I). They were compared to 95 patientsho received a nurse-driven insulin infusion protocol with

296G

.Adam

set

al.

Table 1 Thematic order of studies.Reference Number of patients

and locationTarget blood glucose Method Frequency of

measurementFrequency ofhypoglycaemia

Main results

Theme 1—–surgical interventionsTaylor et al. (2006) Study 8 214 surgical ICU

patients6.6—8.3 mmol/L then4.4—6.1 mmol/L

All patients in a 24-bed surgicalintensive care unit who required i.v.insulin infusions during 3non-contiguous six-month periods from2002 to 2004 were evaluated. In thepre-intervention phase, 71 patientsreceived a physician-initiated insulininfusion without a developed protocol.They were compared with 95 patientswho received a nurse-driven insulininfusion protocol with a target BG of120—150 mg/dL and to 119 patients whoreceived a more stringent protocol witha target BG of 80—110 mg/dL.

1—4 hourly 1.1—3.4%<2.2 mmol/L

There was a stepwise decrease inaverage daily BG levels, from 190 to163 to 132 mg/dL (p < 0.001). The lessstringent protocol decreased the timeto achieve a BG level <150 mg/dL from14.1 to 7.4 h compared withphysician-driven management (p < 0.05)resulting in similar time on an insulininfusion (53 h vs. 48 h). The moreintensive protocol brought BG levels<150 mg/dL in 7.2 h and <111 mg/dL in13.6 h, but increased the length of timea patient was on an insulin infusion to77 h. The incidence of severehypoglycaemia (BG <40 mg/dL) wasstatistically similar between thegroups, ranging between 1.1% and 3.4%.

Dilkhush et al. (2005)Study 10 30 surgical ICUpatients

4.4—7.2 mmol/L Twelve female and 18 male patientswere placed on the protocol. Thepatients ranged in age from 17 to 86years (mean age, 54 years). Twenty-sixpatients (87%) had a documentedinfection. Fifteen patients (50%) wereadmitted with a trauma diagnosis.Other diagnoses included cancer,hypertension, respiratory failure,sepsis, pancreatitis, andgastrointestinal bleeding. Ten patients(33%) had a history of diabetes.Thirteen patients (43%) received TF, 11(36%) TPN, 4 (13%) both TF and TPN,and 2 (6%) dextrose injection containingi.v. fluids. Patients were on the protocolfor an average of 11 days (range, 1—27days).

Hourly until stable,then 4 hourly

0.4%<3.3 mmol/L

2—36 h to reach <7.2 mmol/L (mean12.6 h). After the targeted range wasachieved for a patient, if the bloodglucose level continued to decreaseover three consecutive measurements,the infusion rate was decreased by 0.5or 1 unit/h, depending on the capillaryblood glucose level. Data for the first 30patients were collected fromSeptember 2003 to August 2004. It took2—36 h (mean, 12.6 h) to bring thecapillary blood glucose concentration toless than 130 mg/dL. Among 2845capillary blood glucose measurementsthere were 15 cases of hypoglycaemia(0.4%) requiring treatment with 50%dextrose injection.

Smith et al. (2007) Study 14 145 surgical ICUpatients

4.4—6.1 mmol/L Development and implementation of anurse-initiated, nurse-driven insulininfusion protocol including transition tosubcutaneous insulin. The teamevaluated the protocols focusing ondesign to achieve a target blood glucoseconcentration of 80—110 mg/dL,accepting a more realistic clinicallydesirable range of 80—150 mg/dL, withminimal hypoglycaemia (defined as ablood glucose concentration of<40 mg/dL) and with minimalcalculations to improve accuracy whencalculated by nursing staff.

Hourly 0.01%<2.2 mmol/L

56.5% within target range, 79% withinacceptable range of 4.4—8.3 mmol/L.Data showed that subcutaneous controlis not as tight as that achieved with theinfusion, but it is still within theclinically acceptable range. After twoblood glucose measurements of≥150 mg/dL, patients return to theinsulin infusion. Blood glucose controlwas better using the insulin infusioncompared with the subcutaneousinsulin. In most cases, transition wasnecessary to prepare patients fortransfer to a floor bed where insulininfusions were not administered. Inaddition, the daily adjustments on thebasis of the previous day’s insulin usageimprove control of blood glucose byputting control in the hands of nursing.

Nurse-m

anagedglycaem

iccontrolin

criticallyillpatients

297

Table 2 Thematic order of studies.Reference Number of patients

and locationTarget blood glucose Method Frequency of

measurementFrequency ofhypoglycaemia

Main results

Theme 2—–cardiac interventionsGoldberg et al. (2004) Study 1 52 cardiac ICU

patients5.5—7.7 mmol/L Data from 52 medical intensive care unit

(MICU) patients placed on the IIP. Bloodglucose levels were the primaryoutcome measurement. Relevantclinical variables and insulinrequirements were also recorded. MICUnurses were surveyed regarding theirexperience with the IIP.

Hourly 0.2% of BG<3.9 mmol/L

Using the IIP, the median time to reach targetblood glucose levels (100—139 mg/dL) was 9 h.Once blood glucose levels fell below 140 mg/dL,52% of 5808 subsequent hourly blood glucosevalues fell within our narrow target range; 66%within a ‘‘clinically desirable’’ range of80—139 mg/dL; and 93% within a ‘‘clinicallyacceptable’’ range of 80—199 mg/dL. Only 20(0.3%) blood glucose values were <60 mg/dL,none of which resulted in clinically significantadverse events. In general, the IIP was readilyaccepted by our MICU nursing staff, most ofwhom rated the protocol as both clinicallyeffective and easy to use.

Zimmerman et al. (2004)Study 4 168 cardiac patients 4.4—8.3 mmol/L A nurse-driven insulin infusion protocolwas developed and initiated inpostoperative cardiothoracic surgicalintensive care patients with or withoutdiabetes. In this before—after cohortstudy, 2 periods of measurement wereperformed: a six-month baseline periodprior to the initiation of the insulininfusion protocol (control group, n = 174)followed by a six-month interventionperiod in which the protocol was used(TGC group, n = 168).

1—4 hourly 7.1% <2.2 mmol/L16.7%<3.6 mmol/L

Findings showed percent and time of bloodglucose measurements within the TGC range(control 47% vs. TGC 61%; p = 0.001), AUC ofglucose exposure >150 mg/dL versus time for thefirst 24 h of the insulin infusion (control 28.4 vs.TGC 14.8; p < 0.001), median time to bloodglucose <150 mg/dL (control 9.4 h vs. TGC 2.1 h;p < 0.001), and percent blood glucose <65 mg/dLas a marker for hypoglycaemia (control 9.8% vs.TGC 16.7%; NS).

Theme 3—–ICU/CCU interventionsOrford et al. (2004) Study 9 148 ICU patients 4—7 mmol/L After a six-month introductory period,

an observational study was conductedduring a 10-month period in anAustralian level III intensive care unit toassess the safety and feasibility of aninsulin adjustment protocol to maintainblood glucose concentrations safelywithin a narrow range. The protocolincluded a variable insulin infusion, aconstant caloric source and frequentblood glucose level monitoring to detectand prevent hypoglycaemia.

30 min to 4 hourly 4 episodes<2.2 mmol/L

Over the 10-month period a total of 148 patientswere studied using the protocol and represented13% of all intensive care unit admissions duringthis period. In total, there were 12,623 patienthours ‘on protocol’, with 5603 blood glucoselevels performed. The mean morning bloodglucose level was 6.5 mmol/L and 49% of bloodglucose levels were within the target range of4.1—7.0 mmol/L. There were four recordedincidents of hypoglycaemia, defined as a bloodglucose level of less than 2.2 mmol/L, the lowestat 1.5 mmol/L being the only symptomaticepisode. The incidence of hyperglycaemia (bloodglucose level >10 mmol/L) was 13% of all bloodglucose level measurements.

Balkin et al. (2006) Study 11 90 ICU and CCUpatients

4.4—6.1 mmol/L Matrix chart, insulin up or down0—6 IU/h depending on last two BG

2 hourly 0.09% of BGvalues<2.2 mmol/L

The initial glucose level obtained by bloodglucose meter (BGM) averaged253.5 ± 95.6 mg/dL and fell below 140 within9.3 h on the protocol. The average BGM on theprotocol was 133.5 ± 43.9 mg/dL. Only 0.09% ofall glucose values were <40 mg/dL and insulin hadto be held only 2.2% of the time on the protocol.Physician input was not required and nursingaccuracy in applying the protocol was greaterthan 94%.

298G

.Adam

set

al.

Table 2 (Continued )Reference Number of patients

and locationTarget blood glucose Method Frequency of

measurementFrequency ofhypoglycaemia

Main results

Theme 4—–trauma/ICU interventionsBraithwaite et al. (2006)Study 12 24 trauma ICU

patients4.4—6.1 mmol/L The protocol assigns insulin infusion rate

(IR) for ranges of blood glucose (BG).The columns are arranged in order ofincreasing maintenance rate (MR) forinsulin infusion. Patient columnassignment is determined according torate of change of BG. During stablecolumn assignment, the IR is a functionof column MR and BG. Within-column,the protocol formula provides that (a)for BG between 70 mg/dL and target BG,the IR increases exponentially to thecolumn MR; and (b) for BG above uppertarget BG range, the IR increaseslinearly as an adaptation of the rule of1800, with slope determined by thecolumn MR. Values for IR calculated byformula are rounded to correspond toBG ranges of the table. Performance wasassessed in 27 sequential runs among 24trauma service patients admitted to asurgical intensive care unit (2004—2005).

1—2 hourly 2.4%<3.8 mmol/L0% <2.7 mmol/L

Using point-of-care measurements, meanpre-infusion BG was 230.0 ± 67.9 mg/dL.BG < 140 mg/dL was reached during all 27 runs(median time 5.0 h), and target BG was<110 mg/dL during 25 runs (median time 11.0 h).For the group of runs attaining target beforeinterruption of insulin infusion, the average ± SDof the principal measure of glycaemic control,the within-run mean BG, was 113.7 ± 14.8 mg/dL(coefficient of variation 13%, n = 25 runs). Afterattaining target, the average within-run SD forBG was 22.9 mg/dL. The within-run frequency ofhypoglycaemic measurements (BG < 70 mg/dL) asa percentage of BG determinations was 2.4%. Inthis series, no instance of BG <50 mg/dL wasseen.

Theme 5—–mixed interventionsKanji et al. (2004) Study 2 50 mixed ICU patients 4.5—6.1 mmol/L Combined retrospective prospective

before—after cohort study. Twenty-onebed, medical/surgical ICU in a tertiarycare hospital. Two cohorts of 50consecutive ICU patients requiringinsulin infusions. Patients in the controlcohort received insulin infusions titratedaccording to target blood glucose rangesand sliding scales at the physician’sdiscretion. Patients in the interventionalcohort received an insulin infusionadjusted using a standardized protocoltargeting a blood glucose of4.5—6.1 mmol/l (81—10 mg/dl).

1—2 hourly 4% patients,<2.2 mmol/L

Patients in the interventional cohort reachedtheir target more rapidly (11.3 ± 7.9 h vs.16.4 ± 12.6 h; p = 0.028) and maintained theirblood glucose within the target range longer(11.5 ± 3.7 h/day vs. 7.1 ± 5.0 h/day; p < 0.001)than controls. The standardized protocol yieldeda fourfold reduction in the incidence of severehypoglycaemia (4% vs. 16%; p = 0.046) andreduced the median frequency of dextrose rescuetherapy (0 [0—0.91] vs. 0.17 [0—1.2]episodes/patient per day; p = 0.01) as comparedto controls.

Laver et al. (2004) Study 3 27 mixed ICU patients 4—7 mmol/L Study documents the development androutine use of a simple prescriptiveintravenous insulin infusion protocol forcritically ill patients and compares theresults with previous practice. Duringdevelopment the protocol wasoptimized and practical issues ofimplementation addressed.

1—2 hourly Three BG values,<2.2 mmol/L

The optimized protocol was then used for all ICUadmissions, and a prospectively definedretrospective chart audit performed for the firstmonth of use. Results were compared with asimilar time period the previous year. InSeptember 2002, 27 admissions were started onthe protocol. Blood glucose for the time on theprotocol had a median value of 6.2 (IQR5.9—7.1) mmol/L compared with 9.2 (IQR8.1—10.2) mmol/L for those on insulin in 2001.Blood glucose for the whole ICU stay for those onthe protocol in 2002 had a median value of 6.6(IQR 6.0—7.4) mmol/L compared with 8.6 (IQR8.0—9.4) mmol/L in 2001. Blood glucose for allICU patients in 2002 had a median value of 6.5(IQR 6.0—7.3) mmol/L compared with 7.2 (IQR6.3—8.3) mmol/L in 2001. Three blood glucoserecordings were less than 2.2 mmol/L inSeptember 2002.

Nurse-m

anagedglycaem

iccontrolin

criticallyillpatients

299

Chant et al. (2005)Study 5 44 mixed ICU patients 5.1—8 mmol/L Prospective study with a retrospectivecontrol group. Setting. Amedical—surgical intensive care unit(ICU) in a quaternary care,university-affiliated hospital in an urbancenter. Patients. Eighty-six critically illadult patients (aged 18 years) requiringblood glucose control, with 42 in theretrospective control group and 44 inthe prospective nomogram group.Intervention. Control patients receivedinsulin subcutaneously or intravenouslybased on ad hoc insulin sliding scales;nomogram patients received intravenousinsulin at a rate specified by thenomogram, based on capillary bloodglucose levels measured at the bedside.

1—2 hourly 3.8%<4 mmol/L

Insulin infusion in the prospective patient groupwas titrated by the bedside nurse based on apre-defined nomogram to attain the target bloodglucose level. The retrospective control groupwas used as a comparison to assess the safety andeffectiveness of the nomogram. Fewer patients inthe nomogram (32%) than control (67%) group hada diagnosis of diabetes mellitus on admission.Overall, blood glucose levels in the nomogramgroup were within the target range 52% of thetime versus 20% in the control group (p < 0.001).Morning blood glucose levels were significantlylower compared with the control group(mean ± SD 128 ± 32 mg/dL vs. 176 ± 50 mg/dL,p < 0.001). Nomogram patients achieved targetblood glucose levels faster than control patients(median 15 h vs. 66 h, p < 0.0001). This improvedblood glucose control remained statisticallysignificant after adjusting for baselinedifferences in diabetes status. Hyperglycaemiaoccurred less often in the nomogram than controlgroup (14% vs. 53%, p < 0.0001), andhypoglycaemia occurred more often (3.8% vs.2.2%, p = 0.004). Frequency of severehypoglycaemia was similar in both groups (0.2%vs. 0.4%, p = NS). Such control required slightlymore blood glucose checks/day in the nomogramgroup (7.1 ± 1.5 vs. 5.8 ± 1.1, p < 0.001).

Quinn et al. (2006)Study 6 70 mixed ICU patients 5—7.2 mmol/L Retrospective, observational, chartreview. Medical and surgical intensivecare units (ICUs) in a communityteaching hospital. One hundredforty-three adult patients who receivedinsulin infusions managed at thediscretion of the physician over aone-year period before initiation of theprotocol (control group), and 70patients who received insulin infusionsover a six-month period with infusiondosages titrated by using the protocol(protocol group).

2—4 hourly Mean of 2.13episodes,<3.8 mmol/L perpatient

Episodes of hypoglycaemia, time within targetrange, mean blood glucose concentration,frequency of measurement, length of ICU stay,duration of mechanical ventilation, and overallmortality were collected. Hypoglycaemicepisodes were not significantly different betweenthe groups. Blood glucose concentrations werewithin target range in 34% of all measurements inthe protocol group compared with 23% in thecontrol group (p < 0.001, relative risk [RR] 1.48,95% confidence interval [CI] 1.38—1.58). Oncetarget range was reached on one measurement,43% of concentrations remained in target range inthe protocol group compared with 29% in thecontrol group (p < 0.001, RR 1.47, 95% CI1.38—1.56). Frequency of measurements washigher in the protocol group versus control group(p = 0.01); however, clinical difference wasminimal. Protocol group had lower overallmortality rate (27% [19/70] vs. 32% [46/143],p = 0.45), reduced mean ICU length of stay(16.7—10.6 days vs. 18.4 ± 16.0 days, p = 0.37),and less mechanical ventilation time (16.5 ± 9.7days vs. 17.0 ± 15.0 days, p = 0.79).

300G

.Adam

set

al.

Table 2 (Continued )Reference Number of patients

and locationTarget blood glucose Method Frequency of

measurementFrequency ofhypoglycaemia

Main results

Scheuren et al. (2006) Study 7 29 mixed ICU patients 4.4—6.1 mmol/L Studies evaluating a tight glycaemiccontrol protocol and/or quality ofglucose control that reported originaldata from a clinical trial or observationalstudy on critically ill adult patients.

1—2 hourly <3.8 mmol/L,frequency notreported

49 studies met the inclusion criteria; 30 differentindicators were extracted and categorised intofour nonorthogonal categories: blood glucosezones (for example, ‘hypoglycaemia’); bloodglucose levels (for example, ‘mean blood glucoselevel’); time intervals (for example, ‘time tooccurrence of an event’); and protocolcharacteristics (for example, ‘blood glucosesampling frequency’). Hypoglycaemia-relatedindicators were used in 43 of 49 studies. Bloodglucose level summaries were used in 41 out of49 studies, reported as means and/or mediansduring the study period or at a certain time point(for example, the morning blood glucose level orblood glucose level upon starting insulin therapy).Time spent in the pre-defined blood glucose levelrange, time needed to reach the defined bloodglucose level target, hyperglycaemia-relatedindicators and protocol-related indicators wereother frequently used indicators.

Osbourne et al. (2006)Study 13 20 mixed ICU patients 4.4—6.1 mmol/L The setting was the ICU of a large urbanhospital. The program was composed ofthree components: nurses as leaders, aclinical pathway to identify patients inneed of hyperglycaemia therapy, andimplementation of a redesigned insulininfusion algorithm (the Columnar InsulinDosing Chart). Time to reach a targetglucose range of 80—110 mg/dL(4.4—6.1 mmol/L) was evaluated.

1 hourly 0.9%<3.3 mmol/L

116 ICU nurses were trained in the project. TheColumnar Insulin Dosing Chart was applied to 20patients. The average time required to reach thetarget blood glucose range was 12.8 h.Below-target blood glucose levels were 6.9% ofall blood glucose levels recorded, but only 0.9%were below 60 mg/dL (3.3 mmol/L). There was nosustained hypoglycaemia, and no persistentclinical findings attributable to hypoglycaemiawere noted. Barriers to implementing the projectincluded an increased nursing workload, the needfor more finger-stick blood glucose monitors, andthe need to acquire new finger-lancing devicesthat allowed for shallower skin puncture andincreased patient comfort.

rivrpaat(

4s1aptcTttnlgpttVocIpatsi

I

Osgpcrsgwf2tspah

w

Nurse-managed glycaemic control in critically ill patients

a target of 6.6—8.3 mmol/L (phase II) and 119 patientswho received a more aggressive target of 4.4—6.1 mmol/L(phase III). Patients were well matched in all three phases.There was a significant decrease in mean daily blood glu-cose from 10.5 mmol/L in phase I, to 9.0 mmol/L in phase IIto 7.3 mmol/L in phase III. The commencement of the nurse-driven protocol in phase II decreased the number of hoursto achieve a glucose measurement of less than 8.3 mmol/Lfrom 14.1 to 7.4 h, but this was not further decreased inphase III (7.2 h), despite the fact that starting blood glucoselevels were lower in this group and insulin infusions initiatedearlier. Incidence of severe hypoglycaemia did not differbetween the three phases (range 1.1—3.4%, p ≥ 0.05). Noadverse events were associated with hypoglycaemia in anyof the groups. The method used to implement the protocol— using a reducing target level — helped nurses to adjust tothe new practice of strict glucose control gradually (Tayloret al., 2006) and may have helped the nurses to accept theprotocol.

Dilkhush et al. (2005) (Study 10) developed a protocol forblood glucose control within critical care and evaluated it on30 patients. It took 2—36 h (mean, 12.8 h) to reach the targetrange of 4.4—7.2 mmol/L. There were a total of 2845 bloodglucose measurements, of which 15 were hypoglycaemic(defined as less than 3.3 mmol/L). This was equivalent to0.4%. Comparison was not made to the previous method as itwas extemporaneous and variable dependent upon the pre-scriber. However, previous practice allowed blood sugars toexceed 19 mmol/L and therefore improvement in practicehas occurred.

A nurse-driven protocol was implemented on a surgicalintensive care unit by Smith et al. (2007) (Study 14) and wasused 204 times in 145 patients. Patients were commencedon the protocol if they had two consecutive blood glucosemeasurements more than 8.3 mmol/L. The protocol facili-tated stable blood sugars after the target of 4.4—6.1 mmol/Lwas achieved and 56.5% of blood glucose checks were withinthe target range. Severe hypoglycaemia was defined asblood glucose less than 2.2 mmol/L and was only seen threetimes out of 11,076 readings (0.01%). The mean ± SE timerequired to reach 4.4—6.1 and 4.4—8.3 mmol/L was 6.8 ± 0.4and 3.4 ± 0.5 h, respectively. No significant difference wasnoted between the time taken to reach a blood sugarless than 6.1 mmol/L between diabetics and non-diabetics(7.0 ± 0.5 h vs. 6.4 ± 0.7 h, respectively, p = 0.53). On aver-age, the nurses performed 16.2 blood glucose checks perpatient per day and although there is no control group tocompare this to, it is similar to the findings of the otherresearchers.

Cardiac interventions

Within cardiac ICUs, Goldberg et al. (2004) (Study 1) col-lected data from 52 medical intensive care unit (MICU)patients who were placed on the new insulin infusion pro-tocol (IIP). The IIP was used 69 times in 52 patients.

The median time to reach the target blood glucose(5.5—7.7 mmol/L) was 9 h. Once blood glucose fell below7.8 mmol/L, 52% of 5808 subsequent hourly blood glucosemeasures fell within target range. Twenty (0.3%) bloodglucose values were less than 3.3 mmol/L, none of which

gccmh

301

esulted in adverse events. Safety and efficiency were max-mised by taking into account: (1) the current blood glucosealue, (2) the previous blood glucose value and (3) the cur-ent insulin infusion rate. In other words, the IPP is basedrimarily on the velocity of glycaemic change rather than onbsolute blood glucose values. The ICU nurses also readilyccepted the protocol despite an increased workload andhis was achieved by including them in the research processGoldberg et al., 2004).

Also in cardiac ICUs, Zimmerman et al. (2004) (Study) reported the performance of a nurse-driven insulin infu-ion protocol to maintain blood glucose 4.4—8.3 mmol/L in68 critically ill cardiothoracic patients. The control groupchieved 47% of glucose measures within target range com-ared with 61% of the protocol group (p = 0.001). The medianime to achieve the target glucose range was 9.4 h in theontrol group and 2.1 h in the protocol group (p ≤ 0.001).he percentage of glucose less than 3.6 mmol/L was 9.8% inhe control group and 16.1% in the protocol group (not sta-istically significant p = 0.098). The difference in the meanumber of blood glucose measurements per patient perength of ICU stay was significant; 66 ± 114 in the protocolroup versus 39 ± 183 in the control group (p = 0.01). Thisrotocol was the most effective in terms of achieving thearget blood glucose in a mean time of 2.1 h but it also hadhe highest level of hypoglycaemia. The results achieved byan Den Berghe et al. (2001) also resulted in high levelsf hypoglycaemia and the protocol has consequently beenriticised due to its complexity to implement in the real lifeCU (Meijering et al., 2006), which may be due to the com-lexity of the protocol being used. Zimmerman et al. (2004)lso provides further evidence that a tight glucose controlool increases nurses’ workload. Despite this, the evidenceuggests that the protocol is very effective and markedlymproved previous practice.

CU/CCU interventions

rford et al. (2004) (Study 9) assessed the safety and fea-ibility of an insulin adjustment protocol in an Australianeneral adult intensive care unit. A six-month introductoryeriod was allowed and then an observational study wasonducted over a 10-month period. A total of 148 patientseceived the insulin protocol, representing 13% of all admis-ions during this time period. The mean morning bloodlucose was 6.5 mmol/L and 49% of blood glucose valuesere within the desired range 4.1—7 mmol/L. There were

our recorded incidents of a blood glucose level less than.2 mmol/L, the lowest at 1.5 mmol/L being the only onehat was symptomatic. There were 43 blood glucose mea-urements within the range 2.2—3 mmol/L. Orford et al.ublished an effective protocol but without comparison tonother method of glycaemic control it is impossible to sayow effective.

Balkin et al. (2006) (Study 11) designed a protocol thatas practical to use whilst complex enough to achieve

ood glucose control with a low incidence of hypogly-aemia. The protocol design includes three tables; the userhooses which table to use based on the last blood glucoseeasurement. The protocol was evaluated in 90 patients;

owever, one-hundred-three patient records were accumu-

3

lpbaT7

2optwsreP

T

Avcopgiwb2grOgmw

M

KcoitrpPga(twtApw

t3mtt

(ts6wtph6ru2i

eoa8tgbttawcg(iasgwocptw(

aTtioppttctbtiwcw

02

ated (if the protocol was used more than once in the sameatient it was counted as an additional record). The meanlood glucose measurement initially was 14 ± 5.3 mmol/Lnd fell below 7.8 mmol/L within 9.3 h on the protocol.he mean blood glucose measurement on the protocol was.4 ± 2.4 mmol/L.

Only 0.09% of all glucose measurements were below.2 mmol/L and insulin had to be held only 2.2% of the timen the protocol. A higher mortality rate, 50%, was found inatients that experienced even one episode of glucose lesshan 2.2 mmol/L. Other researchers who carried out similarork did not support this finding; they found no evidence to

uggest that patients who experience hypoglycaemia expe-ienced any increase in mortality (Quinn et al., 2006; Chantt al., 2005; Goldberg et al., 2004; Orford et al., 2004).hysician input was not required on the protocol.

rauma/ICU interventions

study performed by Braithwaite et al. (2006) (Study 12)alidated an insulin infusion protocol to control blood glu-ose levels 4.4—6.1 mmol/L in 27 sequential runs in a groupf 24 trauma patients admitted to a surgical ICU. Meanre-infusion blood glucose was 12.8 ± 3.8 mmol/L. A bloodlucose less than 7.8 mmol/L was reached during all 27 runsn a median time of 5 h. Target blood glucose of 6.1 mmol/Las reached in 25 runs in a median time of 11 h. The meanlood glucose was 7.2 ± 1.4 mmol/L for all 27 runs. For the5 runs that did reach the target, the mean within run bloodlucose was 6.3 ± 0.8 mmol/L. The two runs that did noteach the target blood glucose were of 15 and 58 h duration.nly 2.4% of blood glucose determinations made had a bloodlucose less than 3.9 mmol/L. There were no blood glucoseeasurements less than 2.8 mmol/L. This was comparableith the rate achieved by the other protocols.

ixed interventions

anji et al. (2004) (Study 2) evaluated the safety and effi-iency of a nurse-managed insulin protocol in two cohortsf 50 consecutive medical—surgical ICU patients. Patientsn the control group received a sliding-scale titrated tohe physicians discretion and the interventional cohorteceived an insulin infusion adjusted using a standardizedrotocol with a target blood glucose of 4.5—6.1 mmol/L.atients within the interventional group reached the tar-et more rapidly (11.3 ± 7.9 h vs. 16.4 ± 12.6 h; p = 0.028)nd maintained their blood glucose within the target longer11.5 ± 3.7 h vs. 7.1 ± 5.0 h/day; p = 0.046) compared to con-rols. The median number of hours that the insulin infusionas held for hypoglycaemia was shorter in the interven-

ional group, however it did not meet statistical significance.total of 35% more blood glucose measurements were

erformed in the protocol group, increasing the nursingorkload significantly.

In developing a simple prescriptive protocol for rou-

ine use in critically ill patients, Laver et al. (2004) (Study) investigated a total of 27 admissions, who were com-enced on the protocol. Blood glucose for the time on

he protocol had a median value of 6.2 mmol/L (interquar-ile range 5.9—7.1 mmol/L) compared with 9.2 mmol/L

t([g2

G. Adams et al.

interquartile range 8.1—10.2 mmol/L) for those in the con-rol group (p ≤ 0.0001). Blood glucose for the whole ICUtay for those on the protocol had a median value of.6 mmol/L (interquartile range 6.0—7.4 mmol/L) comparedith 8.6 mmol/L (interquartile range 8.0—9.4 mmol/L) in

he control group (p = 0.0002). Blood glucose for all ICUatients during 2002 (when the new protocol was used)ad a median value of 6.5 mmol/L (interquartile range.0—7.3 mmol/L) compared with 7.2 mmol/L (interquartileange 6.3—8.3 mmol/L) in 2001 (prior to the protocol beingsed) (p = 0.016). Three blood glucose values were less than.2 mmol/L in the protocol group in 2002, there were nonen the control group.

A study performed by Chant et al. (2005) (Study 5)valuated the effectiveness, safety and associated patientutcomes of a simplified nurse-directed insulin protocol tochieve a blood glucose level of 5.1—8 mmol/L. A total of6 patients were enrolled in the study, forty-two in the con-rol group and forty-four in the protocol group. The controlroup patients received insulin on an ad hoc sliding scaleasis either subcutaneously or intravenously as directed byhe physician. Fewer patients in the protocol group (32%)han the control group (67%) had a diagnosis of diabetes ondmission. Blood glucose levels in the protocol group wereithin target range 52% of the time compared with 20% in theontrol group (p ≤ 0.001). Protocol patients achieved tar-et blood glucose values faster than control group patientsmedian time 15 h vs. 66 h, p ≤ 0.0001). The improvementn blood glucose control remained statistically significantfter adjustment for the baseline differences in diabetictatus. Hyperglycaemia occurred less often in the protocolroup than in the control group (14% vs. 53%, p = 0.0001),hilst hypoglycaemia (less than 4 mmol/L) occurred moreften (3.8% vs. 2.2%, p = 0.004). Episodes of severe hypogly-aemia were similar between the two groups (0.2% vs. 0.4%,= NS). The evidence shows that the protocol improved con-

rol without compromising safety. More blood glucose checksere required in the protocol group than the control group

7.1 ± 1.5/day vs. 5.8 ± 1.1/day, p ≤ 0.001).Quinn et al. (2006) (Study 6) evaluated the effectiveness

nd safety of maintaining a blood glucose of 5—7.2 mmol/L.he setting was a mixed medical—surgical ICU, the con-rol group was formed from 143 patients that receivednsulin infusions at the discretion of the physician over ane-year period. The protocol group was made up of 70atients that received insulin infusions over a six-montheriod whose infusion was titrated as directed by the pro-ocol. There was a statistically significant difference in theype of admissions between the groups; an increased per-entage of patients were admitted to the medical ICU inhe protocol group (77% vs. 55%, p = 0.001), the remaindereing admitted to the surgical ICU. As mentioned previouslyhe systemic corticosteroid use can inhibit insulin by caus-ng peripheral insulin resistance (Rady et al., 2006). Useas more frequent in the protocol group (64%) than in theontrol group (37%, p = 0.002). Blood glucose concentrationsere within the target range 34% of all measurements in

he protocol group compared with 23% in the control groupp ≤ 0.001, relative risk [RR] 1.48, 95% confidence intervalCI] 1.38—1.58). The mean ± SD time to reach target bloodlucose was similar between the two groups (21 ± 15.3 h vs.6.2 ± 29.2 h protocol vs. control group, p = 0.06). The fre-

Aotds4dPbtmawcc

shhtDnfb

gmccoviivoht

omtv(icmuidwiwtaccr

Nurse-managed glycaemic control in critically ill patients

quency of blood glucose measurements was higher in theprotocol group (54 ± 50) versus the control group (37 ± 40,p = 0.01). Episodes of hypoglycaemia were not significantlydifferent between the two groups, although the percentagewas higher in the protocol group (43% compared with 36%in the control group). The protocol group had lower overallmortality (27% vs. 32%, p = 0.45), reduced mean length of ICUstay (16.7 ± 10.6 days vs. 18.4 ± 16.0 days, p = 0.37) and lessventilator time (16.5 ± 9.7 vs. 17.0 ± 15.0, p = 0.79). How-ever, changes in practice occurred during the study periodthat may have contributed to this effect. These included theuse of activated protein C, corticosteroids and early goaldirected therapy in the fight against sepsis (Dellinger et al.,2004) and the establishment of an in-house rehabilitationfacility leading to more timely transfers out of ICU. Despitethis, Quinn et al. have demonstrated an improvement inpractice with the new protocol.

A modified nurse-driven insulin infusion protocol wasused by Scheuren et al. (2006) (Study 7) and comparedthe results to that of their traditional protocol at main-taining a goal range of 4.4—6.1 mmol/L. This cohort studyof 58 patients allocated 29 patients to the control groupand 29 patients to the protocol group. Results were anal-ysed separately for diabetic and non-diabetic patients. Inboth the control group and protocol group there were 16patients with diabetes and 13 without. The mean lengthof ICU stay was lower for both diabetics and non-diabeticsin the protocol group. The protocol group also had fewerpatients acquiring renal dysfunction (46.7% diabetics, 38.5%non-diabetics) compared with the control group (18.8% dia-betics, 34.5% non-diabetics). They also had a lower meannumber of days on mechanical ventilation (18 ± 26 days fordiabetics, 23 ± 5.7 days non-diabetics in the control groupand 8.8 ± 10.2 days for diabetics and 15.9 ± 18.7 days in theprotocol group). The results for time to reach target aresplit into two ranges, 4.4—6.1 and 6.2—8.3 mmol/L. Patientsin the protocol group required less time to achieve glu-cose control for both ranges. To reach a blood glucose of4.4—6.1 mmol/L for patients with diabetes was 11.5 h andwithout diabetes 8 h in the protocol group in comparison to21.5 h for diabetics and 12 h for non-diabetics in the controlgroup. Similar results were achieved in the 6.3—8.3 mmol/Lrange, with the exception of non-diabetics treated with thetraditional protocol being the fastest to reach control in amedian time of 3 h. The analysing of results separately forpatients with and without diabetes reduces further alreadysmall sample sizes, reducing the power of the researcher todraw strong conclusions (Polit and Beck, 2006). This protocolwould need to be validated in a larger study to allow statisti-cal analysis to prove effectiveness prior to implementation.

Osbourne et al. (2006) (Study 13) assessed the feasibilityof a nurse-driven effort to improve hyperglycaemia man-agement in a pilot study of 20 patients using a drip chartformat in a mixed ICU. Increasing columns of the chart cor-respond to a higher insulin sensitivity factor. The user movesup a column in the chart if the current blood glucose ishigher than the last blood glucose, enabling adjustment to

the patients’ unique insulin sensitivity. The chart was des-ignated the Columnar Insulin Dosing Chart. There were atotal of 19 patients, although one patient used the protocoltwice, creating two records. The mean time to achieve thetarget blood glucose range of 4.4—6.1 mmol/L was 12.8 h.

bcgfid

303

ll patients reached the target range except for two. Onef these improved but did not reach the target range beforehe infusion was discontinued, the other died on the thirday without reaching the target level. Only 6.9% of mea-urements recorded a blood glucose measurement below.4 mmol/L but only 0.9% were considered hypoglycaemic,efined as a blood glucose value less than 3.3 mmol/L.ost-study interviews of the nursing staff uncovered somearriers to implementation. More patients were identifiedhat would need to be treated with an insulin infusion andore frequent blood glucose measurements and infusion

djustments increased the workload of the nurses. Thereas also insufficient bedside blood glucose testing devices toonduct testing and nurses expressed concern about the dis-omfort to patients of performing hourly finger stick tests.

A major criticism of all these studies, however, is the lowample sizes used and the timeframe over which the workas been carried out. Studies in non-critically ill patientsave demonstrated the benefit of nurse directed effortso improve diabetes care (Feddersen and Lockwood, 1994;avies et al., 2001) and there is evidence to indicate thaturse-driven care in critical units can provide a success-ul method when implementing glycaemic control protocols,ut this is not extensive.

The studies that did compare their protocols to a controlroup (study 1, 2, 3, 4, 5, 6, 7 and 8) all showed an improve-ent in practice from the method previously used. In most

ases there was also a reduction in episodes of hypogly-aemia. Zimmerman et al. (2004) recorded a higher numberf episodes of hypoglycaemia in the protocol group (9.8%s. 16.7%, p = 0.098), but this was not statistically signif-cant. Chant et al. (2005) recorded only a small increasen episodes of hypoglycaemia in the protocol group (3.8%s. 2.2%, p = 0.004) but this was significant. However, nonef the episodes of hypoglycaemia were associated with anyarm and the benefits of tight glycaemic control outweighhe small risks of hypoglycaemia (Borggreve et al., 2008).

There is, therefore, a much greater need for the usef larger randomised controlled trials, which would provideore in depth information about the cause-and-effect rela-

ionship. An example of this is that carried out on intensiveersus conventional glucose control in critically ill patientsNICE, 2009), which found that intensive glucose controlncreased mortality among adults in the ICU and a blood glu-ose target of 180 mg or less per decilitre resulted in lowerortality. Within 24 h after admission to an intensive care

nit (ICU), adults who were expected to require treatmentn the ICU on three or more consecutive days were ran-omly assigned to undergo either intensive glucose control,ith a target blood glucose range of 81—108 mg per decil-

tre (dL) (4.5—6.0 mmol/L), or conventional glucose control,ith a target of 180 mg/dL or less (10.0 mmol/L or less). Of

he 6104 patients who underwent randomisation, 3054 weressigned to undergo intensive control and 3050 to undergoonventional control; data with regard to the primary out-ome at day 90 were available for 3010 and 3012 patients,espectively. The two groups had similar characteristics at

aseline. A total of 829 patients (27.5%) in the intensive-ontrol group and 751 (24.9%) in the conventional-controlroup died (odds ratio for intensive control, 1.14; 95% con-dence interval, 1.02—1.28; p = 0.02). The treatment effectid not differ significantly between operative (surgical)

3

pdt≤tcnt(t

pnfaoqdmb

igpieteapae

piopb

ifdhtsi

lWdtnfcHwgso

iT

esl

co

L

Mpptarmptacfb

C

Tamm

ictmrotih

odadtetidbrtmdd

04

atients and non-operative (medical) patients (odds ratio foreath in the intensive-control group, 1.31 and 1.07, respec-ively; p = 0.10). Severe hypoglycaemia (blood glucose level,40 mg/dL) was reported in 206 of 3016 patients (6.8%) in

he intensive-control group and 15 of 3014 (0.5%) in theonventional-control group (p < 0.001). There was no sig-ificant difference between the two treatment groups inhe median number of days in the ICU (p = 0.84) or hospitalp = 0.86) or the median number of days of mechanical ven-ilation (p = 0.56) or renal-replacement therapy (p = 0.39).

The major disparity between this study and the 14 studiesresented earlier is that the NICE study was a large, inter-ational, randomised trial with over 6000 patients, whichound that intensive glucose control increased mortalitymong adults in the ICU. Of the 14 studies presented herenly some of the researchers developed their protocols asuality improvement projects, but more importantly theyid not compare their new protocols to previous practiceethods. Moreover, full validation of these protocols woulde required before the protocols could be instigated.

What the studies did, however, establish was an increasen nurses’ workload due to the increased frequency of bloodlucose checks (study 2, 5, 6, 13 and 14). However, therotocols were still accepted by the nurses as they werenvolved in the development and review process (Osbournet al., 2006) and were surveyed and felt that the benefito the patient outweighed the increased workload (Taylort al., 2006). The increase in nurses’ workload needs to becknowledged and considered before implementing a newrotocol and involving nurses in the process will help them toccept it into practice, despite the increased work (Staintont al., 1998).

A major criticism of all these studies is impact on nursingractice. These include: (1) frequency of glucose monitor-ng; (2) methods used to monitor glucose levels; (3) riskf hypoglycaemia and (4) inadequate nutrition status ofatients and (5) problems that arise as a result of a com-ination of some of the above or all.

In terms of the frequency of glucose monitoring, it ismportant to establish an agreed timeframe of monitoring,or example, every hour until such time that the patient’sesired blood glucose parameters, as previously mentioned,ave been achieved. If the timeframe needs to be changed,hen it is essential that agreed consultation occurs betweentaff. Once this has been established, the frequency of mon-toring can be reduced to, for example, 2—4 hourly.

With regards to the methods used to monitor glucoseevels, it is important for consistency to be maintained.ith the use of glucometers, consistency is not maintained

ue to volume taken, method used at obtaining sample andhe correct reading of the result. In addition to this, theyeed to be calibrated frequently but this is often not per-ormed in clinical practice. An alternative and much moreonsistent method is that using arterial blood gas samples.ere, the method used and the volume taken is, on thehole, consistent irrespective of who is taking it. The bloodas analysers automatically calibrate the results from the

et volume obtained and a consistently accurate result isbtained.

Despite the importance of consistent glucose monitor-ng, the patient can still remain at risk of hypoglycaemia.his can be due to inadequate titration of insulin deliv-

etcat

G. Adams et al.

ry/administration by inexperienced junior members oftaff or an unexplained diminution of patient blood glucoseevels.

On initial admission, the nutritional status and normogly-aemic levels of patients are sometimes relegated in orderf importance due to the stabilisation of the patient.

imitations

any of the papers included in this review used small sam-le sizes, using larger randomised controlled trials wouldrovide more information about the cause-and-effect rela-ionship, however, no randomised controlled trials werevailable looking at nurse-directed protocols. Some of theesearchers developed their protocols as quality improve-ent projects and did not compare their new protocol torevious practice methods. These protocols achieved similarime to target blood sugar, time within target blood sugarnd frequency of hypoglycaemia as the protocols that didompare their practice to the previous method. However,ull validation of one of these protocols would be requiredefore it was instituted.

onclusion

ight glycaemic control is a vital component in the man-gement of critically ill patients. There is evidence thataintaining normoglycaemia in these patients reduces bothortality and morbidity (Van Den Berghe et al., 2001, 2006).One hundred and eighty-eight potentially relevant stud-

es were identified for the review, fourteen met the inclusionriteria. The studies that compared their protocol to a con-rol group all showed an improvement in practice from theethod previously used. In most cases, there was also a

eduction in episodes of hypoglycaemia. In the one episodef hypoglycaemia, no harm occurred and the benefits werehought to outweigh the risks. In the protocols that weremplemented as quality improvement projects, episodes ofypoglycaemia were infrequent.

An insulin infusion protocol (IIP) that utilises the previ-us and current blood glucose measurements, in order toetermine the new infusion rate, is relevant, appropriatend proven at maintaining glycaemic control than the tra-itional sliding scale method. A protocol that allows nurseso commence and maintain the infusion is as safe and moreffective than the traditional sliding scale method and isherefore a feasible method to control blood glucose in crit-cal care. It is important that nurses accept the new protocolue to the increase in their workload; this can be achievedy involving them in the implementation process. Futureesearch should focus on (1) determining the most effec-ive glucose target range to maximally reduce mortality andorbidity, (2) comparing protocols to each other and toetermine if one method is more effective than others, (3)etermining the length of time tight glucose control is nec-

ssary and methods to avoid rebound hyperglycaemia whenhe infusion is stopped, (4) determining if a different proto-ol is necessary depending on the diagnosis of the patient,nd (5) identifying methods to reduce nurses’ workload inhis area.

M

T

O

O

P

Q

R

R

S

S

S

S

T

V

V

V

V

Nurse-managed glycaemic control in critically ill patients

References

Balkin M, Mascioli C, Smith V, Alnachawati H, Mehrishi S, SaydainG, et al. Achieving durable glucose control in the intensive careunit: a new practical IV insulin protocol. Diabetes/MetabolismResearch and Reviews 2006;23(1):49—55.

Ball C, DeBeer K, Gomm A, Hickmann B, Collins P. Achievingtight glycaemic control. Intensive and Critical Care Nursing2007;23(3):137—44.

Boord JB, Graber AL, Christman JW, Powers AC. Practical manage-ment in critically ill patients. American Journal of RespiratoryCritical Care medicine 2001;164:1763—7.

Booth A. In search of evidence: informing effective practice. Journalof Clinical Effectiveness 1996;1(1):25—9.

Borggreve H, Zijlstra J, Ligtenberg J. Benefits of tight glycaemiccontrol still outweight the harm of hypoglycaemia. Critical CareMedicine 2008;36(2):663—4.

Braithwaite S, Edkins E, MacGregor K, Sredzinski E, Housten M,Zarzaur B, et al. Performance of a dose-defining insulin infusionprotocol among trauma service intensive care unit admissions.Diabetes Technology and Therapeutics 2006;8(4):476—88.

Carlson G. The value of point of care testing when instituting aninsulin drip protocol. Critical Care Nursing 2001;24(1):49—53.

Chant C, Wilson G, Friedrich J. Validation of an insulin infusionnomogram for intensive glucose control in critically ill patients.Pharmacotherapy 2005;25(3):352—9.

Davies M, Dixon S, Currie C, Davies R, Peters J. Evaluation of a hospi-tal diabetes specialist nursing service: a randomised controlledtrial. Diabetes Medicine 2001;18(4):301—7.

Dellinger R, Carlet J, Masur H, Gerlach H, Calandra T, CohenJ, et al. Surviving sepsis campaign guidelines for manage-ment of severe sepsis and septic shock. Critical Care Medicine2004;32(3):858—73;Department of Health. The new NHS: modern, dependable. Lon-don: Department of Health; 1997.

Dilkhush D, Lannigan J, Pedroff T, Riddle A, Tittle M. Insulin infusionprotocol for intensive care units. American Journal of Health-System Pharmacy 2005;62(21):2260—4.

Feddersen E, Lockwood D. An inpatient diabetes educators impacton length of hospital stay. Diabetes Educator 1994;20:125—8.

Goldberg P, Siegal M, Sherwin R, Halickman J, Lee M, Bailey V,et al. Implementation of a safe and effective insulin infu-sion protocol in a medical intensive care unit. Diabetes Care2004;27(2):461—7.

Institute of Healthcare Improvement Critical Care. Sepsis.Severe sepsis bundles; 2005, http://www.ihi.org/IHI/topics/criticalcare.

Kanji S, Singh A, Tierney M, Meggison H, McIntyre L, Hebert C.Standardization of intravenous insulin therapy improves the effi-ciency and safety of blood glucose control in critically ill adults.Intensive Care Medicine 2004;30(5):804—10.

Krinsley J. Effect of an intensive glucose management protocolon the mortality of critically ill adult patients. Mayo Clin Proc2004;79(8):992—1000.

Laver S, Preston D, Turner C, McKinstry C, Padkin A. Imple-menting intensive insulin therapy: development and audit ofthe Bath Insulin Protocol. Anaesthetics and Intensive Care2004;32(3):311—6.

Meijering S, Corstjens A, Tulleken J, Meertens J, Zijlstra J, Ligten-

berg J. Towards a feasible algorithm for tight glycaemic controlin critically ill patients: a systematic review of the literature.Critical Care 2006;10(1):R19.

McCowen K, Malhotra A, Bistrian B. Stress induced hyperglycaemia.Critical Care Clinics 2001;17(1):107—24.

W

Z

305

ontori VM, Bistrian BR, McMahon MM. Hyperglycemia in acutely illpatients. JAMA 2002;288:2167—9.

he NICE-SUGAR Study Investigators. Intensive versus conventionalglucose control in critically ill patients. New England Journal OfMedicine 2009;360:1283—97.

rford N, Stow P, Green D, Corke C. Safety and feasibility of aninsulin adjustment protocol to maintain blood glucose concen-trations within a narrow range in critically ill adult patients inan Australian level III adult intensive care unit. Critical Care andresuscitation 2004;6(2):92—8.

sbourne R, Cook C, Stockton L, Baird M, Harmon V, Keddo A, etal. Improving hyperglycaemia management in the intensive careunit: preliminary report of a nurse-driven quality improvementproject using a redesigned insulin infusion algorithm. The Dia-betes Educator 2006;32(3):394—403.

olit D, Beck C. Essentials of nursing research: methods, appraisaland utilization. Philadelphia: Lippincott, Williams and Wilkins;2006.

uinn J, Snyder S, Berghoff J, Colombo C, Jacobi J. A practicalapproach to hyperglycaemia management in the intensive careunit: evaluation of an intensive insulin infusion protocol. Phar-macotherapy 2006;26(10):1410—20.

ady M, Johnson D, Patel B, Larson J, Helmers R. Corticosteroidsinfluence the mortality and morbidity of acute critical illness.Critical Care 2006;10(4):R101.

osenberg W, Donald A. Evidence based medicine: an approachto clinical problem solving. British Medical Journal1995;310(6987):1122—6.

cheuren L, Baetz B, Cawley M, Fitzpatrick R, Cachecho R. Phar-macist designed and nursing-driven insulin infusion protocol toachieve and maintain glycaemic control in critical care patients.Journal of Trauma Nursing 2006;13(3):140—5.

mith P, James T, Lorentzon M, Pope R. Shaping the facts: evidence-based nursing and healthcare. London: Churchill Livingstone;2004.

mith A, Udekwu P, Biswas S, Harvey E, Bullock A, Barnes M, etal. Implementation of a nurse-driven intensive insulin infusionprotocol in a surgical intensive care unit. American Journal ofHealth-System Pharmacy 2007;64(14):1529—40.

tainton M, Harvey S, McNeil D, Emmanuel E, Johnson C. Thetransforming power of research on practice: involving practi-tioners in analysis. International Journal of Nursing Practice1998;4(4):220—4.

aylor B, Schallom M, Sona C, Buchman T, Boyle W, Mazuski J, etal. Efficacy and safety of an insulin infusion protocol in a surgi-cal ICU. Journal of American College of Surgeons 2006;202(1):1—9.

an Den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyn-inckx F, Schetz M, et al. Intensive insulin therapy in criticallyill patients. New England Journal of Medicine 2001;345(19):1359—67.

an Den Berghe G. How does blood glucose control with insulinsave lives in intensive care? The Journal of Critical Investigation2004;114(9):1187—95.

an Den Berghe G, Wilmer A, Hermans G, Meersseman W, WoutersP, Milants I, et al. Intensive insulin therapy in the medical ICU.New England Journal of Medicine 2006;354(5):449—61.

asa F, Molitch M. Prolonged critical illness management of longterm acute care. Clinics in Chest Medicine 2001;22(1):193—208.

oodrow P. Intensive care nursing. A framework for practice. Lon-don: Routledge; 2001.

immerman C, Mlynarek M, Jordan J, Rajda C, Horst H. An insulininfusion protocol in critically ill cardiothoracic surgery patients.The Annals of Pharmacotherapy 2004;38(7—8):1123—9.