In 2015, our medical intensive care unit (MICU) Inpatient Evaluation Center (IPEC) quality scores for care of patients with severe hyperglycemia (blood glucose >300 mg/dL) were above the Veterans Health Administration (VHA) national aggregate for comparable size Veterans Administration organizations. This was not within expected levels despite efforts of the prior year to update our insulin infusion titration guide.
AVAILABLE KNOWLEDGE AND RATIONALE
Hyperglycemia is associated with increased mortality, morbidity, longer hospital stays, and associated costs.1 Cichosz and Schaarup2 noted that the mortality rate among intensive care unit (ICU) patients with diabetes (N = 27 458) was 9% for observed hyperglycemia and 6.5% for patients without hyperglycemia (P < .001). Length of ICU stay was also slightly longer for patients with hyperglycemia (median of 1.9 days) than for other patients (median of 1.5 days; P < .001).
Our definition of safe blood glucose targets has evolved over time. The American Association of Clinical Endocrinologists and the American Diabetes Association now advocate an inpatient blood glucose target glucose range of 140 to 180 mg/dL for the majority of critically ill patients and noncritically ill patients.3,4 Chang et al5 noted significantly worse outcomes among patients with diabetic hyperglycemia (blood glucose >200 mg/dL) who were admitted to the ICU after controlling for gender, age, and preexisting comorbidities. It was also noted that patients with diabetic hyperglycemia had a significantly longer length of stay (10.1 vs 7.4 days; P = .006) than the nondiabetic normoglycemia group. Moghissi et al1 caution that the ability to achieve glucose targets safely depends on multiple factors, including titration protocol characteristics, patient characteristics, staffing ratios, and provider acceptance.
The purpose of this performance improvement project was to explore the gaps in care contributing to hyperglycemia in the critically ill medical patient and implement nursing interventions to improve outcomes.
In 2015, our IPEC hyperglycemia quality scores were higher than the national average despite previous efforts to update our insulin infusion titration guide. Our team consisted of dedicated nurses (unit-based leaders, a collaborative care case manager, a clinical nurse specialist, an endocrine nurse practitioner, and a critical care staff nurse). We convened to conduct an assessment and uncovered these gaps in care:
- Need for a more user-friendly insulin infusion titration guide indicating when to notify the provider. The sooner the provider is notified, the sooner an insulin infusion can be started.
- Need to review with nurses the difference between the various causes of severe hyperglycemia and diabetes management in the critically ill adult such as diabetic ketoacidosis (DKA), hyperosmolar hyperglycemic state (HHS), and hyperglycemia caused by steroid treatment. Each specific disease state dictates appropriate treatment and goals.
- Need to identify barriers to mitigating hyperglycemia. Factors included provider delay in orders, steroid treatments, and nursing awareness.
- Need for ongoing audits to provide real-time feedback to the staff and providers to avoid missed opportunities to initiate an insulin infusion.
- Need to orient new interns, residents, fellows, and attending physicians to the nurse-driven protocol.
- Need to address the knowledge gap on how to appropriately dose insulin for the glycemic excursions following steroid administration.
Interventions began with a review of our current insulin infusion calculator. The team chose to amend this existing document to include notifying the physician for insulin infusion if 2 blood glucose readings of more than 300 mg/dL occurred in a 12-hour period. Two consecutive readings at this high level were selected because this would eliminate occasional elevations due to admission hyperglycemia or other causes. This amended approach was implemented in January 2016.
Education was an important factor in this initiative and required the team to review with nurses and other staff the differences between the existing diabetes protocols for hyperglycemia, DKA, and HHS and also ensure those protocols were available for the new medical staff rotating to the MICU. A knowledge gap had been identified on how to appropriately dose insulin for steroid-related hyperglycemia, and nurses and physicians were educated on these. This education was initiated in June 2016 and remains ongoing with new staff.
Another intervention was the development of a steroid guidance reference sheet (see Supplemental Digital Content, Figure 1, available at: http://links.lww.com/JNCQ/A520). This was developed by the Endocrine Diabetes team and is available in bedside resource binders for the nursing staff to share with the rotating medical staff, as well as posted in the physician conference room along with the insulin infusion calculator and laminated flow sheets of all 3 hyperglycemia protocols.
In September 2016, a staff nurse volunteered to track our data. This nurse was given a daily report of hyperglycemic episodes on MICU patients, which was generated through our Collaborative Care Case Manager and was available Monday through Friday. An electronic medical record audit was triggered for 2 consecutive blood glucose readings of more than 300 mg/dL in a 12-hour period. Tracking also included when the resident was contacted by the nurse and/or insulin infusion started. If an infusion was not ordered, other actions taken were recorded. The audit included compliance with documentation in the nursing treatment note, and potential causes such as steroid use, DKA, and issues of no action taken were noted. We found that the auditor needed to be released from patient care to review the records and follow-up 1:1 with the nursing staff.
Results were reviewed at every staff nurse meeting. The staff nurse auditor suggested that the insulin infusion be included as an option in the hyperglycemia nursing treatment note. That change has enhanced tracking of insulin infusions for the MICU patients.
Study of the interventions
Our interventions and timelines included the following:
- Ongoing resident/intern orientation every 2 weeks since 2014, which includes resources for hyperglycemia management (bedside protocol binder);
- In January 2015, we changed the target to 140 to 180 mg/dL on insulin infusion;
- In January 2016, we revamped the insulin infusion protocol to notify the physician for 2 consecutive blood glucose values of more than 300 mg/dL in a 12-hour period;
- In June 2016, we modified our education emphasis on diabetes protocols to nurses and physicians;
- In September 2016, we initiated staff nurse auditing and for the auditor to report on hyperglycemia events at monthly staff meetings to provide timely feedback;
- In December 2016, hyperglycemic events were added to our safety huddles at shift change;
- In June 2017, we presented our steroid guide; and
- Finally, in September 2017, insulin infusion was added to the hyperglycemia template for nursing documentation.
The interventions with specific timelines were compared with IPEC scores to determine the effectiveness of the interventions and where changes might be needed.
The VHA IPEC hyperglycemia graph indicates that our overall rate has trended below the national average for the first time in years (see Supplemental Digital Content, Figure 2, available at: http://links.lww.com/JNCQ/A521). When we began our journey to improve our IPEC hyperglycemia scores, we had a few interventions in place; however, they were not done consistently. We identified gaps in care, modified our protocol, educated the nursing staff, developed a process for educating the new medical staff rotating to the unit, and placed protocols for hyperglycemia management at the bedside as a reference for providers.
While the focus on hypoglycemia in the critical care patient has been important in the last few years, caregivers cannot lose sight of hyperglycemia and the complications that can ensue. Moghissi et al1 note that outcomes such as dehydration, electrolyte disturbances, infection complications, and poor wound healing can result when hyperglycemia is severe.
The establishment of a nurse-driven protocol for hyperglycemia management and surveillance was effective for preventing hyperglycemic episodes on our MICU. This protocol provided for a consistent approach to the prevention of high-risk hyperglycemia.
Access to the roster of patients with blood glucose levels above 300 mg/dL remains available Monday through Friday. While this roster was valuable in summarizing patient data and identifying the initial problem, the opportunity to expand this to 7 day a week availability needs to be explored. Another limitation was the multiple interventions to address hyperglycemia. It is difficult to identify one strategy that was most effective in reducing the number of hyperglycemic episodes of more than 300 mg/dL. Continuing the process of educating medical and nursing caregivers is important to maintaining success of the project.
Nurses provide surveillance and assessment 24 hours a day and remain a constant presence at the bedside of the critically ill. This presence affords for success of a nurse-driven hyperglycemia reduction program through collaboration with the health care team, avoiding adverse outcomes for patients. Through the establishment of this nurse-driven initiative, the multidisciplinary team was able to standardize care and treatment to minimize the episodes of hyperglycemia and its impact on recovery of the critically ill adult.
1. Moghissi ES, Korytkowski MT, DiNardo M, et al American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Endocr Pract. 2009;15(4):353–369.
2. Cichosz SL, Schaarup C. Hyperglycemia as a predictor for adverse outcome in ICU patients with and without diabetes. J Diabetes Sci Technol. 2017;11(6):1272–1273.
3. Moghissi E, Inzucchi S. The evolution of glycemic control in the hospital setting. In: Drazin B, ed. Managing Diabetes and Hyperglycemia in the Hospital Setting, A Clinician's Guidebook. 1st ed. ADA Alexandria, VA: Wolfe Rinke Associates; 2017:1.
4. American Diabetes Association. 14. Diabetes care in the hospital: standards of medical care in diabetes—2018. Diabetes Care. 2018;41(suppl 1):S144–S151.
5. Chang MW, Huang CY, Liu HT, Chen YC, Hsieh CH. Stress-induced and diabetic hyperglycemia associated with higher mortality among intensive care unit trauma patients: cross-sectional analysis of the propensity score-matched population. Int J Environ Res Public Health. 2018;15(5):E992. doi:10.3390/ijerph15050992.