PURPOSE: The purpose of this study was to examine nurses’ adherence to a continuous insulin infusion (CII) protocol in adults having CAGBS. Literature suggests protocols for tight glycemic control may lead to increased incidence of complications. There is however very little evidence to demonstrate practice patterns associated with the implementation and management of CII protocols.
METHODS: Retrospective review of medical records from a convenience sample of 100 consecutive CABG cases from July to December 2009, at a single University affiliated hospital was conducted. One observer gathered data on patient demographics, operative characteristics and protocol adherence using a standardized proforma. Outcomes were tracked from admission to ICU until the cessation of CII. According to institutional protocol CII was to commence at 2.5 units/hour if blood glucose (BG) level was > 9.1 mmol/L but < 15 mmol/L. Rate adjustment was dependent on BG level measured hourly for three hours if adjustment was necessary. The primary endpoint was protocol adherence during CII. Initiation, monitoring and dose adjustment violations were tracked.
RESULTS: CII was commenced for 79 patients, 47 (59.5%) who had no diabetic history. At commencement BG level was on average 8.8 mmol/l (SD = 2.4). Infusions continued for a median of 27 hours (Q1 16, Q1 36) after surgery and it took approximately 6.3 hours to achieve target BG levels. Only 52.6% of BG results were within protocol target range of 6 to 9 mol/L. Two patients experienced an episode of hypoglycaemia requiring intervention. Initiation violations occurred in more than 50% of patients requiring CII. BG levels were monitored less frequently than was recommended (n = 455, 62.7% violations) and there were 270 (37.3%) episodes of incorrect dose adjustment less than suggested.
CONCLUSIONS: Adherence to the CII protocol was poor but not to the detriment of patient outcomes. Nurses were conservative in CII initiation and rate adjustment.
CLINICAL IMPLICATIONS: In order to determine the efficacy of practice protocols outcomes must be evaluated in the context of optimal protocol adherence.
DISCLOSURE: The following authors have nothing to disclose: Heba Al Mattar, Rochelle Wynne, Shan Shan Law, James Tatoulis
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