PURPOSE: Hyperglycemia among inpatients, irrespective of cause, is associated with adverse outcomes. It is recommended that most critically ill patients be managed on long-acting insulin (preferably intravenous infusion), with a target blood glucose range of 140-180mg/dL for patients in the medical intensive care unit (MICU). We aimed to improve the rates of adherence to these guidelines and thereby the overall glycemic control in our MICU.
METHODS: An electronic medical tool was developed and validated for extraction of unit-level glycemic control data. Using fishbone analysis, interviews of health care personnel and index case reviews, suitable tests of change (TOCs) were chosen.
RESULTS: In the first TOC, a poster was displayed in the unit that reminded health care personnel about the implications of inpatient hyperglycemia and current recommendations regarding glycemic control in the MICU. One month later, a second TOC was employed: an article on the same topic in the monthly “MICU newsletter” for nurses. The unit’s average blood glucose during the one month immediately prior to the first TOC was 145mg/dL and the percentage of patients on any anti-hyperglycemic regimen (including oral hypoglycemic agents or sliding scale insulin) that were on long-acting insulin (subcutaneous or intravenous) was 51%. The corresponding numbers during the month after the first TOC were 137mg/dL and 62%, respectively. During the month after the second TOC, they were 138mg/dL and 63%, respectively.
CONCLUSIONS: Using group educational interventions (poster and newsletter), we were able to improve the rates of long-acting insulin administration when indicated and also the unit’s overall glycemic control. Our findings are significant even though our unit-level analysis did not exclude normoglycemic patients or those receiving “de-escalated/comfort care.”
CLINICAL IMPLICATIONS: Lack of awareness on part of resident physicians and/or nurses can be a major impediment to guidelines-based management of hyperglycemia in the MICU. Simple and cost-effective educational interventions can be employed to successfully overcome the same.
DISCLOSURE: The following authors have nothing to disclose: Majid Shafiq, Muhammad Khan, Sheila Bharmal, Justin Rykowski, Carolyn Holder, Ray Snider, Jason Stein, Micah Fisher
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