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American Journal of Critical Care. 2007;16: 589-598
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An Efficiency Evaluation of Protocols for Tight Glycemic Control in Intensive Care Units

By Mark A. Malesker, PharmD, Pamela A. Foral, PharmD, Ann C. McPhillips, RN, BA, CCRN, Keith J. Christensen, PharmD, Julie A. Chang, MD and Daniel E. Hilleman, PharmD. Mark A. Malesker and Pamela A. Foral are associate professors, Keith J. Christensen is an assistant professor, and Daniel E. Hilleman is a professor in the Department of Pharmacy Practice, and Julie A. Chang is a clinical fellow in the Division of Pulmonary and Critical Care, Department of Internal Medicine, Creighton University Medical Center, Omaha, Nebraska. Ann C. McPhillips is a critical care/clinical educator at Alegent Health Immanuel Medical Center, Omaha, Nebraska.

Corresponding author: Mark A. Malesker, PharmD, Creighton University Medical Center, 2500 California Plaza, Omaha, NE 68178 (e-mail: malesker{at}creighton.edu).

Background The efficiency of protocols for tight glycemic control is uncertain despite their adoption in hospitals.

Objectives To evaluate the efficiency of protocols for tight glycemic control used in intensive care units.

Methods Three separate studies were performed: (1) a third-party observer used a stopwatch to do a time-motion analysis of patients being treated with a protocol for tight glycemic control in 3 intensive care units, (2) charts were retrospectively reviewed to determine the frequency of deviations from the protocol, and (3) a survey assessing satisfaction with and knowledge of the protocol was administered to full-time nurses.

Results Time-motion data were collected for 454 blood glucose determinations from 38 patients cared for by 47 nurses. Mean elapsed times from blood glucose result to therapeutic action were 2.24 (SD, 1.67) minutes for hypoglycemia and 10.65 (SD, 3.24) minutes for hyperglycemia. Mean elapsed time to initiate an insulin infusion was 32.56 (SD, 12.83) minutes. Chart review revealed 734 deviations from the protocol in 75 patients; 57% (n = 418) were deviations from scheduled times for blood glucose measurements. The mean number of deviations was approximately 9 per patient. Of 60 nurses who responded to the workload survey, 42 (70%) indicated that the protocol increased their workload; frequency of blood glucose determinations was the most common reason.

Conclusions Nurses spend substantial time administering protocols for tight glycemic control, and considerable numbers of deviations occur during that process. Further educational efforts and ongoing assessment of the impact of such protocols are needed.




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An Insult to Nurses!
Jon Landis
AJCC Online, 12 Nov 2007 [Full text]

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