- May 30, 2018
The month of May is host to several healthcare recognitions; there’s National Nurses Week, National Hospital Week, Stroke Awareness Month, and Mental Health Awareness Month. But, among all these recognitions, there is one that doesn’t get nearly as much attention: National Critical Care Awareness and Recognition Month (NCCARM).
NCCARM honors the intensive care unit (ICU) teams that make a difference every day caring for patients and families in what is often their most vulnerable moments in life. Nearly 80% of all Americans will suffer, or know someone who is suffering, from a life-threatening illness or injury, requiring the support of providers in the ICU. These patients, who may be battling an acute illness or complexities from a chronic illness, are in a state of stress, which in turn results in an increase in insulin resistance and greater likelihood for hyperglycemia. With high glucose levels, patients become more at risk for infection, take longer to heal, and are more prone to longer length of stay and readmissions.
This NCCARM, we are paying the attention it deserves by focusing on the best practices for insulin therapy in the critical care setting.
IV Insulin Therapy
Intravenous (IV) insulin has been shown to be the best method of achieving glycemic targets in the critical care setting. Providers should recommend the use of IV insulin when a patient is in a state of hyperglycemic crisis, such as diabetic ketoacidosis and hyperosmolar hyperglycemic state, has a blood glucose greater than 180 mg/dL at two consecutive checks, and/or is in surgical and post-operative care. The American Diabetes Association (ADA) consensus statement recommends glycemic control targets for critically ill patients between 140-180mg/dL, with lower goals appropriate for tighter control in certain patient populations.
Timeliness of Checks
The timeliness of IV insulin therapy is extremely important. Providers should monitor blood glucose as ordered on time. Failure to do so may result in hypoglycemia or lack of control. In fact, delayed blood glucose checks and insulin delivery is the most significant indicator of episodes of hypoglycemia and hyperglycemia. The frequency of blood glucose checks on IV insulin therapy should be set between every 30 minutes to 2 hours, depending on the patient case.
Adherence to Protocol
According to an analysis by Patient Safety & Quality Healthcare, insulin is the cause for 39% of all adverse drug events where harm occurred. When the protocol is not followed exactly, and patients receive too much or too little insulin, the patient’s safety could be in danger. To avoid malglycemia, as the ADA 2018 Consensus Statement states, “insulin should be administered using a validated written or computerized protocol that allows for predefined adjustments in the insulin dosage based on the glycemic fluctuations.”
Across the hospital, and particularly in the ICU, there needs to be a systematic approach to insulin dosing that facilitates safe practices and reduces the risk for errors. The process, protocol, and timing must be followed to ensure the correct dose of insulin is given at the right time. To ensure standardization, many hospitals have made strides by implementing glycemic management committees, providing ongoing physician and nurse education, and offering dedicated resources such as pocket cards and unit glycemic management champions to assist with difficult patient cases.
To achieve these best practices, hospitals have also made significant improvements in their glycemic management with the use of EndoTool®. Using EndoTool, the protocol is personalized for each patient and provides a precise insulin dose to more rapidly achieve control, while avoiding hypoglycemia. The application assists with timeliness with a reminder of the next check and alarms that can be turned on. EndoTool has been shown to dramatically improve adherence and standardization of care to ensure patients are receiving the safest insulin therapy.
While critical care professionals have no shortage of priorities to be concerned about while caring for their patients, adhering to these insulin therapy best practices can greatly improve patient safety and outcomes, which like NCCARM, is something worth the attention.