In Brief

Since 2005, Crozer-Keystone Health System has been participating in the VHA Transformation of the Intensive Care Unit (TICU) initiative. The goal of the TICU program is to achieve better clinical outcomes, fewer adverse events and greater patient satisfaction with ICU care through a series of interventions that achieve significantly better outcomes when implemented together rather than individually. One of these interventions is improving glycemic control.

Critically ill patients on a ventilator are prone to develop hyperglycemia because the stress reaction of the illness makes them more insulin resistant, whether or not they were diabetic previously. Research has shown that hyperglycemia decreases the ability of white blood cells to fight infection, leaving the critically ill patient with decreased immunity and heightened vulnerability.  Numerous studies have shown that improving glycemic control results in better outcomes for critically ill patients, including fewer blood transfusions, less renal failure, fewer days on ventilator and shorter stays. 

In March 2005, Crozer-Keystone set a goal of tightening glycemic control by maintaining 75 percent of ICU ventilator patients within the blood glucose range of 70-120mg/Dl.   

Developing a Protocol

The history of Crozer-Keystone’s path to improved glycemic control dates back to 2004 when the Crozer Regional Trauma Center at Crozer-Chester Medical Center observed that glycemic control in the Shock Trauma Unit (STU) was less than optimal. Riad Cachecho, M.D., medical director of the Trauma Center, established a multidisciplinary team that included Lucinda Scheuren, clinical coordinator of the Pharmacy at Crozer, Ruth Ann Fitzpatrick, M.D., chief of Edocrinology at Crozer, and Medical Intensive Care Unit nursing staff to address the issue. 

The team reviewed the literature about blood glucose control in ICUs across the country. After selecting the approach that best fit the Crozer STU, they developed a new insulin infusion protocol. “Pharmacy played a key role in this process,” says Cachecho, noting that Sheuren wrote the Crozer protocol.  After successfully piloting the new protocol in the STU, the team applied it to other medical and surgical patients at Crozer where it was equally effective.

Multidisciplinary teams were also established at Delaware County Memorial Hospital (DCMH) and Taylor Hospital, and the new insulin infusion protocol was adopted throughout Crozer-Keystone, with some variations to best suit the needs of each hospital.

Over the last few years, the team effort to continuously examine and improve the process and protocols to achieve tight glycemic control have enabled the ICUs  across the system to achieve dramatic improvement. In  July 2006, only 41 percent of patients maintained a morning blood glucose in the acceptable range.  In 2008, 67 percent of ventilated patients in our ICU’s had a blood sugar in the 70–120 mg/Dl range, a 62 percent improvement in less than two years. 

In addition, these results are consistent and reproducible. This fiscal year to date (July 2007 – April 2008), the ICUs across the system have hit 71 percent compliance, beating their 65 percent goal.    In addition, at DCMH, their team efforts to constantly improve the infusion protocol have cut their incidence of hypoglycemia nearly in half to 3 percent, well below the national average of more than 5 percent. 

In the fourth quarter of 2007, Crozer-Chester Medical Center’s MICU, CVU and STU ranked among the top VHA hospitals nationally for glycemic control, placing third, fifth and sixth respectively.  Crozer also ranked second out  of a group of 130 hospitals sharing results through their point-of-care testing lab vendor.

“This is a very worthy and important initiative and I’m greatly appreciative of the efforts that have been put into place throughout the system at each of our hospitals to improve glycemic control in critically ill patients,” says Eric Dobkin, M.D., vice president of Quality and Patient Safety. “The results have been outstanding thanks to the commitment of our multidisciplinary teams, and there’s no question in my mind that this initiative is beneficial to patients.”

“The nurses are the ones who have made this work through their diligence,” says Gary Wendell, M.D., medical director of the MICU at Crozer . “Although this is a very labor intensive protocol, the nurses really got behind it because they understand the value of glycemic control.”

Education was very important, according to Daniel DuPont, D.O., chief of  Pulmonology at Taylor. “We ran sessions to explain how glycemic control for post-op and ICU patients reduced side effects and morbidity and shortened length of stay.  They came to realize that normalizing blood sugar is just as important as maintaining a normal temperature or blood pressure.”

“This has been a team effort that takes the support of the physicians and pharmacists, but the work and commitment of the nurses has been the key element of our success,” emphasizes Eileen Young, assistant vice president of Utilization & Outcomes.

“We are very proud of the vital role that our nurses have played in this endeavor,” says Nancy Bucher, Vice President and Chief Nursing Officer, CKHS. “Their excellent work is enabling us to improve care for our most critically ill patients.”

“This effort is all about providing the best possible care, ensuring patient safety and preventing adverse events,” adds Gerald Meis, D.O., pulmonologist at Springfield.

The glycemic control protocol is being used in all Crozer-Keystone hospitals with some variations at each site.

Best Practices

The ICU nursing staff manages patients by monitoring their blood glucose with hourly finger stick tests. This enables the nursing staff to respond to blood glucose changes and adjust the continuous drip insulin dosage before the blood glucose gets too far out of control.  Before 2005, patients were checked every four to six hours.

The nursing staff makes adjustments to the insulin dosage based on blood glucose changes, not just blood glucose value.  The amount of insulin given depends on how much the blood glucose has gone up or down since the last hourly finger stick, as well as the blood glucose value.

The current protocol, which improved on the column system first implemented in 2005, uses a narrower range of blood glucose values in each column to determine the appropriate insulin dosage.   For example, instead of using a blood glucose range from 80 to 120, that range has been broken down on the chart into two smaller ranges of 80 to 100 and 101 to 120. 

“We changed this because if you give the same insulin dose to a patient whose blood glucose, for instance, is 91 as you do to one whose reading is 119, the patient at 91 might get more than needed and the one at 119 might get less than needed,” explains Patricia LaPorta, RN, BSN, MS, CCRN, BC, critical care clinical nurse educator at DCMH.  The same approach is used for hyperglycemic and hypoglycemic control.

The majority of antibiotics are now administered to patients in normal saline solution instead of dextrose. The nursing staff and clinical pharmacists at DCMH met to discuss concerns about the effects of antibiotics administered in dextrose. In a subsequent study conducted by the pharmacists, more than half the patients given antibiotics in the smallest possible volume of dextrose (50 cc) experienced out-of-range blood glucose levels.  The switch to saline solution has contributed to the overall improvement in glycemic control.

The nursing staff initiated a change to variable depth lancets for hourly finger stick tests to reduce discomfort for the patients. “The staff was really concerned about causing the patients additional pain with such frequent finger sticks,” relates LaPorta. “Now they can use the smallest depth lancet needed to obtain the required blood supply.”

The clinical pharmacist rounds on ICU patients every day, evaluates their blood glucose values, determines their 24-hour average, then consults with the physicians or notes on the chart whether the patient should be on the insulin infusion protocol. 

“The involvement of the pharmacists has helped us to manage these patients very effectively,” notes Thomas Prestel, M.D., chief of Pulmonology at DCMH.

The ICU nursing staff continuously evaluates the protocol and recommends changes to the multidisciplinary team. “Nursing representatives are always invited to our meetings and we welcome their feedback,” says Cachecho. “We always give priority to the nurses’ recommendations over the team’s because the nurses are the ones applying the protocol at the bedside. They know what works.”