Introducing intensive insulin therapy: the nursing perspective

Abstract

Intensive insulin therapy (IIT) for the management of high blood glucose can reduce mortality and morbidity in the critically ill. However, there is little published literature on how to implement it successfully. The aim of this study is to chronicle the development and difficulties encountered in implementing an IIT protocol in a critical care unit in a district general hospital. A nurse-led protocol was developed. Qualitative audit was undertaken during development and implementation to identify potential problems with using the Bath Insulin Protocol. Regular feedback sessions were introduced to encourage change and further identify problem issues. Qualitative audit led to changes in practice for individual nurses and changes to other unit protocols. The main change for individual nurses was to measure blood glucose hourly using a bedside glucometer. The unit's feeding and drug dilution policies were identified as a potential cause of glucose instability and were modified. To implement IIT successfully, it is necessary to consider changing working practices and to identify other unit protocols which can cause glucose instability. The additional nursing workload must be considered and appropriate means of supporting staff identified.

Avaliação da percepção de enfermeiros sobre três protocolos para controle glicêmico em pacientes críticos

“…All nurses involved in the administration of the protocols filled out the questionnaires, with a very low frequency of unanswered questions. Only few studies examined nurses' perceptions as to intensive insulin therapy (10,12,(14)(15)(16) . We are not aware of any study comparing nurses' views of three different protocols implemented simultaneously.…”

“…Blood glucose control in intensive care should be a nurse-driven task (10)(11)(12)15,16) . Nurse-driven protocols achieve the best results in terms of glucose control and safety (9)(10)(11) .…”

“…Some studies were performed to evaluate the workload, time, and costs related to algorithms for tight glycemic control. Only a few studies examined the perception of nurses regarding intensive insulin therapy (12,(14)(15)(16) . However, we are not aware of any studies that have compared nurses' views on three different protocols implemented simultaneously as part of a randomized controlled trial.…”

Glycemic Control in Intensive Care Unit: A Proposal for the Safe Application in the Post-Surgical Patient

“…Even nursing research was keen to emphasize that the safe implementation of a protocol for blood glucose management in the intensive care, the first concern of nurses has increased the risk of the occurrence of hypoglycemic events (20).…”

Automatisation du contrôle strict de la glycémie en réanimation

“…De plus, les indicateurs de qualité du contrôle glycémique utilisés dans les diverses études sont très nombreux et très variables d'une étude à l'autre [35]. Ces indicateurs peuvent mesurer la qualité de l'algorithme en terme de respect de la cible (temps passé dans la cible, index d'hyperglycémie, glycémie moyenne sur l'ensemble du séjour, glycémies matinales), en termes d'effets secondaires (indicateurs d'hypoglycémie nécessi-tant l'adoption d'un seuil commun d'hypoglycémie sévère en réanimation), en termes de charge de travail soignante [36] et en termes d'acceptation des recommandations par les soignants, aussi bien celles concernant les débits d'insuline proposés que les horaires de mesure (explorant ainsi l'exportabilité d'un protocole informatique en dehors du service clinique où son développement est intervenu [20]). Des auteurs ont proposé un indicateur composite explorant tout autant la capacité à ne pas dépasser la cible qu'à éviter les épisodes d'hypoglycémie sévère [37].…”