Posted in Critical Care on May 11, 2018
During a critical illness, the body’s response to stress can result in hyperglycemia (blood glucose levels of >12 mmol/L), even in patients without diabetes. Uncontrolled hyperglycemia during a stay in the intensive care unit can increase the risk of bloodstream infections, acute renal failure, prolonged inflammation, polyneuropathies, and even death1,2.
Although attempting to control glucose within very strict parameters (4.5 to 6.0 mmol/L) has the potential to cause further harm, more recent research shows optimal levels to target at <10 mmol/L3,4. Maintaining blood glucose levels below this target in critically ill adults requires a careful balance of intravenous insulin and nutrition to ensure levels are controlled but do not fall below hypoglycemic thresholds.
Our team is here to support you, as you work toward improving glycemic control in your intensive care unit. Get started with the resources through the links below or contact us today.
- Initiate a regional written policy to prevent hyperglycemia in all adult surgical/medical ICU patients with or without diabetes mellitus
- Use a validated written or computerized protocol/algorithm for an intravenous insulin regimen that allows for predefined adjustments in the insulin infusion rate based on glucose levels and insulin dosage. If your ICU does not currently have a glucose protocol/algorithm, check our resources page for samples of protocols with demonstrated safety and efficacy, which you can adapt to fit your local context
- Use the insulin protocol to control blood glucose below a threshold of 10.0 mmol/L4. Avoid hypoglycemic events (reporting threshold of <3.5 mmol/L)
- Do not attempt to tightly control glucose to achieve targets of normoglycemia (blood glucose levels of 4.4 to 6.1 mmol/L)5. Strict glucose control has been associated with increased hypoglycemic events, which may increase mortality4
- Identify and collect data on balancing measures, to monitor for unintended consequences of improvement efforts. These should include safety measures, particularly for episodes of severe hypoglycemia
- Ensure that all physicians, nurses, hospital pharmacists, dieticians and other clinical staff in the ICU have been trained in the insulin regimes. Support ongoing peer discussion and provider education
- Work within your local context to use strategies to increase compliance with your organization’s policy, including the use of computer decision support systems, provider reminder systems, preprinted orders, auditing and feedback
- Use an identify-and-mitigate strategy to immediately remedy patients who are not on the protocol, or do not have appropriate glycemic control. Provide real-time clinician feedback. Analyze and eliminate system failures
- Engage and involve patients and families in their glycemic care
In order to achieve these goals, teams working on glycemic control should set specific goals and target outcomes, measure and analyze data, and revise for continual improvement and sustainability. This can be accomplished using quality improvement processes and methodology.
Frequently Asked Questions
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.
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.
British Columbia has 29 adult Intensive Care Units. All adult ICU’s will be collecting data for quality improvement in glycemic control.
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.
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.
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.
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.
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.
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.
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.
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.
Form a multidisciplinary ICU improvement committee to set an aim, identify system improvement, and test changes. Check the CCM guidelines above for strategies to achieve optimal glycemic control in your ICU. Contact us for more information on quality improvement methodology and support.
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.
Resources You Might Be Interested In...
- Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. NEJM. 2001;345 (19): 1359-67
- Van den Berghe G, Wilmer A, Hermans G, et al. Intensive insulin therapy in the medical ICU. NEJM. 2006;354(5) 449-61
- Griesdale DE., de Souza RJ, van Dam RM et al. Intensive insulin therapy and mortality among critically ill patients. A meta-analysis including NICE-SUGAR study data. CMAJ 2009; 180(8): 799-800
- 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
- Qaseem A, Humphrey LL, Chou R, et al. Use of intensive insulin therapy for the management of glycemic control in hospitalized patients: A clinical practice guidelines from the American College of Physicians. Ann Intern Med. 2011;154:260-267.