BC Patient Safety & Quality Council

Glycemic Control – FAQ

Rationale

If we improve our glycemic control, will we see lower mortality rates?

It is difficult to generalize from current literature whether improving glycemic control in critically ill patients leads to lower mortality rates. Landmark trials in Belgium suggest that targeting a blood glucose concentration of 4.4-6.1 mmol/L reduced mortality and morbidity1,2, but other investigators have not been able to replicate these findings. More recently, the international multicenter Normoglycemia in Intensive Care Evaluation-Survival Using Glucose Algorithm Regulation (NICE-SUGAR) study reported increased mortality with this approach mainly due to hypoglycemia3,4.

Based on this results and best evidence, expert groups now recommend insulin treatment be started in critically ill patients when the glucose concentration exceeds 10 mmol/L with a target of glucose concentration of 8-10 mmol/L. Whether adequate glucose control in an ICU setting would affect mortality directly or indirectly through implementation of best evidence practices remains unknown.

Measurement

What is the data collection for?

The primary purpose of the data collection is to guide quality improvement towards evidence-based practice in critically ill patients in intensive care units across BC.

Is every hospital collecting this data?

British Columbia has 29 adult Intensive Care Units. All adult ICU’s will be collecting data for quality improvement in glycemic control.

Does this improvement effort include pediatric patients? Why not?

No. The body of medical evidence does not support glycemic control in critically ill pediatric patients. Attempting to control glucose may lead to harm in this population.

Are we collecting data on every patient on insulin infusions?

No. A sampling strategy has been developed, based on the minimum number of patients needed to be able to detect an improvement over time at each site. In some cases, particularly in smaller ICU’s, this may require sampling all patients on insulin infusion.

Do we collect and include data on patients on a Diabetic Ketoacidosis (DKA) protocol ?

Yes. Although the insulin protocols may be different, the goals for these patients are the same as for patients who have hyperglycemia due to other causes – to minimize hyperglycemia and hypoglycemia. Thus we collect and include data on patients on a DKA protocol as well.

Why use glycemic index as a method of analysis for glucose control?

Calculating the glycemic index provides us with a metric for time and magnitude of glucose measurements that occur over the hyperglycemic threshold. This quantifies the value and length of time the patient remained in a hyperglycemic state; both are variables that can be detrimental to critically ill patients.

Point-of-care blood glucose testing is not as accurate as lab testing. Why are you collecting data from both?

Both measurements are used to guide clinical decision-making, and are therefore accurate enough to guide quality improvement. Use of both data sources is in keeping with well-known large clinical trials.

My site already collects and sends glucose data to the International Nutrition Survey. Are you duplicating these efforts?

The International Nutrition Survey looks at best nutrition practices in critically ill patients. Their purpose and clinical practice guidelines are in alignment with CCM. They require a single morning glucose value, and sites collect data for a short period of time. CCM builds on this by giving sites a more detailed picture of blood glucose control for patients on insulin throughout the year and over the entire duration of their ICU stay. Glucose values collected for CCM can be used to submit to the INS. Participating in both improvement initiatives is a great way to work towards excellence in nutrition practices and glycemic control.

Improvement

What if my ICU does not have an insulin protocol?

Check our resource page for protocols used at other local institutions. With your multidisciplinary ICU team, select and adapt one to best fit your local context. Analyze your data and revise your protocol if necessary.

What if I’m not confident that the data collected is accurate?

As critical care units are collecting their own data, this issue is best addressed within your internal team. Quality improvement methodology can be used to improve accuracy of your data collection. Contact us for details.

Our site data hasn’t been as good as we would like. How do we improve?

Form a multidisciplinary ICU improvement committee to set an aim, identify system improvement, and test changes. Check the CCM guidelines for strategies to achieve optimal glycemic control in your ICU. Contact us for more information on quality improvement methodology and support.

Discussion and Communication

We’ve had some success and learned some valuable lessons along the way that might be useful for similar ICU’s. How can we share this information?

Share your success within our online community network (under development). Present your journey through one of our interactive critical care support webinars (contact us for more information).

 

I’d like to be more involved in improving quality of care in ICU patients. Who can I contact?

We’re happy to have you involved and would love to talk to you more about building local leadership in quality improvement. Contact our Quality Leader or Clinical Leader at BCPSQC anytime.

References

  1. Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. NEJM. 2001;345 (19): 1359-67
  2. Van den Berghe G, Wilmer A, Hermans G, et al. Intensive insulin therapy in the medical ICU. NEJM. 2006;354(5) 449-61
  3. Griesdale DE., de Souza RJ, van Dam RM et al. Intesive insulin therapy and mortality among critically ill patients. A meta-analysis including NICE-SUGAR study data. CMAJ 2009; 180(8): 799-800
  4. NICE-SUGAR study investigators, Finfer S, Chittock DR Su SY, et al. Intensive versus conventional glucose control in critically ill patients. NEJM. 2009; 360(13): 1283-97