Camille Haycock, MS, RN, CNS
Clinical Nurse Specialist
Banner Good Samaritan Medical Center
Introduction and study purpose:
Hyperglycemia and insulin resistance are two abnormalities that are common in critically ill patients. In a retrospective chart review of patients sustaining sternal wound infections s/p cardiovascular surgery, it was noted that 71% of these patients had consistent blood glucose levels >180 mg/dl during their post-operative ICU stay. In an effort to reduce sternal wound infections at Banner Good Samaritan Medical Center, a multidisciplinary team was assembled and various processes were evaluated. Among those procedures assessed within the CVICU was the management of hyperglycemia in the immediate post-operative period.
After a comprehensive literature search and in consultation with cardiovascular surgeons, ICU intensivists, pharmacy, and an endocrinologist, an aggressive insulin protocol was developed that allowed nursing personnel to incrementally increase IV insulin dosing, based upon hourly glucose levels, to a target blood glucose range of 80-110 mg/dl.
Interdisciplinary staff education was completed, including pharmacy personnel, medicine, anesthesia, and nursing. Under the direction of the CVICU medical director, 25 patients were placed on the aggressive insulin protocol over a 6-week period. Data were collected on these patients including baseline glycosylated hemoglobin, mean ICU admit-to-discharge blood glucose, average length of time to obtain target range, and baseline blood glucose.
Among those patients (N=25) placed on the intensive insulin protocol, 40% were known diabetics. The mean baseline HgA1C was 6.8. The mean baseline blood glucose on arrival to CVICU was 152 mg/dl. It took an average of 10 hours for patients to reach target range, and the mean admit-to- hospital discharge blood glucose was 113 mg/dl. Mean blood glucose during the patient’s CVICU stay was 102 mg/dl.
Implications for research, practice and/or policy:
Strict glycemic control (blood glucose at or below 110 mg/dl) in the critically ill patient has been shown to reduce morbidity and mortality. With the implementation of an intensive insulin protocol in the CVICU, blood glucose levels can be maintained within target range (80-110).