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The institution did not have a policy or strategy to manage patients on insulin pumps, particularly during operative or procedural events. Education of nurses in the organization was variable, and with the advent of many new insulin and oral glycemic control medications, development of standardized and updated education was needed to avoid errors in insulin administration.

Additionally, turnover of nursing staff, high numbers of nursing students and physician residents, and use of agency personnel yielded new groups of professionals entering the organization who required introduction to new glycemic control standards. The SUGAR team established small working groups to develop specific changes in practice with clear timelines for dissemination throughout the organization.

A uniform approach was designed to address elements needed for successful implementation: protocol and guideline development, education and strategies for pilot testing in a few units, followed by systemwide dissemination. Development teams were assimilated for each specific initiative. Since the project began, the following best-practice designs were accomplished:.

The reason for this approach was to streamline and provide a standard approach based upon the best scientific evidence available and to reduce variation in practice related to glycemic control. Each of these strategies for glycemic control was implemented in a systematic manner, driven by advanced practice nurses, physicians and nurse educators in specific practice areas. All of these initiatives required presentation to appropriate committee meetings such that everyone was on board with the new initiatives, including specific practice committee groups, pharmacotherapy and therapeutics, physician leadership groups and collaborative practice teams.

This involvement from key leaders in each area of practice was essential for buy-in and adoption of new strategies. Educational programs were developed for each guideline and were made available to all areas of practice. A specific website for the SUGAR project and online education was established to facilitate the education process on each initiative. The educational offerings included slide presentations, a posttest, and any associated order sets, protocols, references or guidelines on each topic.

These programs were made mandatory for all nurses in the acute care setting where the content applied to their area of practice. During the implementation phase, active presence was required to reinforce IV insulin protocols. This included active involvement of physicians, pharmacists, advanced practice nurses and educators to guide staff through the new protocol during the adjustment and education phases.

Transitioning Safely from Intravenous to Subcutaneous Insulin

This was extremely important for successful implementation as the IV insulin physician order sets were complex and required guidance until fully adopted by staff. This strategy was also important for patient safety to make sure the elements are followed and for efficacy of dosing for glycemic control. We encountered some resistance from nurses and physicians on adopting tight glycemic control practices. They had voiced concern over putting the patient at risk when putting the patient on IV insulin to lower control levels and frequent finger sticks for hourly monitoring.

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Over time, however, clinicians were able to appreciate the success of the infusion orders in controlling BG without adverse side effects and acquired mastery of using the protocol, and the initial resistance has diminished. Several focus studies have been done during implementation of the glycemic control initiatives with the SUGAR project in the critical care units prospectively.

We studied the impact of our IV insulin infusion orders on reaching BG target range, compliance with the protocol, and hypoglycemic events [14]. This was possible through coordination with the point-of-care-testing coordinator to receive reports and data to evaluate BG monitoring patterns and blood glucose results. As a result, we could determine the impact of IV insulin on the number of tests performed during the study period.

After these studies were complete, we were able to revise the IV insulin orders consistent with our findings. An additional study was conducted on the nursing work involved, perceptions on frequent BG monitoring and titration of insulin therapy, and approximate costs, and was able to evaluate the impact on average blood glucose values from the units over time []. In this study, we found that while nurses believed that glycemic control was important, the work effort required was extensive and cumbersome.

Estimated costs associated with glycemic control over a 1-year period in the intensive care units alone approximated USD , Nursing time spent on glycemic control alone averaged approximately 2 hours of direct patient care time. Recommendations from this study were to find new ways of BG monitoring, such as automated systems and non-invasive monitoring. At present, new strategies are being developed for glycemic control and by industry to develop such devices and will have a potential impact on glycemic control in the future [].

We also realized that we needed more point-of-care BG monitoring machines in each unit to accommodate increases in BG monitoring with IV insulin infusion. Part of monitoring the impact of the SUGAR project involved coordination with the pharmacist in charge of recording medication errors. The team started receiving reports of medication errors related to glycemic control and insulin administration.

These were reported in leadership meetings, and ways to improve patient safety in glycemic control were addressed. Throughout the initiative, an increased awareness of the importance of glycemic control was established by grand rounds presentations for nurses, physicians, pharmacists and other multidisciplinary groups.

The SUGAR project initiatives and results of focused studies were made public in all relevant committees and administrative groups. Unit education was conducted where glycemic control strategies were being adopted and a new computer-assisted program for glycemic control is being developed for systemwide access to education.

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The SUGAR team also posted results of the pilot tests for safety and efficacy for wide dissemination to all staff. Currently, all new nurses hired in the organization, including student nurses and their educators, are required to complete the SUGAR education as part of their orientation to our system. We are developing strategies for unit designation for acute diabetes states and management, with highly specialized education for all staff physicians, nurses, clinical technicians for highly specialized care in glycemic control.

Patient education programs have also been implemented to address the need for continued education for patients with diabetes and newly diagnosed cases of diabetes. All of the glycemic control initiatives are being disseminated to all the hospitals within the organization using the same methods that were successful at the initial site of implementation. In summary, glycemic control is a multidisciplinary, multiprofessional process. Safe and effective means for glycemic control requires developing a strategic plan by an organization with a systemwide approach to glycemic control with the common goal of improving patient care and outcomes.

Involvement of key team players and leaders are essential for successful implementation of glycemic control strategies. May contain information that is not supported by performance and intended use claims of Radiometer's products. See also Legal info. Radiometer and acutecaretesting. Printed from acutecaretesting. April Systemwide implementation of glycemic control. Since the project began, the following best-practice designs were accomplished: Hypoglycemia protocols, guidelines and education for adults and pediatrics IV insulin order set for critical care, guidelines and education for adults Subcutaneous insulin regimen for adults, education Policy and procedures and guidelines for glycemic control with insulin pump Uncontrolled diabetic states: diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome order sets, guidelines and education The reason for this approach was to streamline and provide a standard approach based upon the best scientific evidence available and to reduce variation in practice related to glycemic control.

Inpatient Diabetes Management

Stress hyperglycemia and prognosis of stroke in nondiabetic and diabetic patients. Stroke ; Stress hyperglycemia and increased risk of death after myocardial infarction in patients with and without diabetes: a systematic overview. Lancet ; Mar 4; Continuous IV insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Ann Thorac Surg ; 67 2 : The influence of diabetes mellitus on postoperative infections.

Best Practice Guidelines

Clinical strategies to maintain a euglycemic state during critical illness involve frequent monitoring for BG and implementing intravenous IV insulin infusions to control BG within strict parameters. Many and varied glycemic control protocols are used to maintain BG to normoglycemic levels.

However, the two variables that are common in all protocols are frequent hourly or less BG measurements and careful titration of IV insulin dosing to achieve BG levels within a specified target range.

This process is done to achieve targeted BG levels in the shortest time possible in a safe manner in order to limit the time of exposure of the patient to hyperglycemia. Strategies for glycemic control include increased monitoring for BG in patient situations where hyperglycemia poses a threat. Examples include patients who were critically ill, high-risk surgical patients, those with acute cardiovascular disorders, and the use of drugs that cause hyperglycemia, such as catecholamine infusions and steroid administration.

More protocols involve hourly monitoring and titration of intravenous insulin to a desired target BG. Studies on implementation of such clinical protocols to reduce BG to normoglycemic range has resulted in improved outcomes and reduced complications. In our organization, we began IV insulin infusions in the critical care areas first, pilot tested them, and refined the process before implementing them in specific step-down units and other hospitals within our organization.

Each step of implementation was carefully planned and rolled out in a specific manner, mostly for patient-safety concerns and adoption within the unit culture. At our institution, we recognized that we had issues with glycemic control. In December , a multidisciplinary team was assembled of all major players and areas of the hospital where glycemic control was important.

Examples of disciplines and roles of team members included nurses, point-of-care-testing laboratory coordinator, physicians, certified diabetes educators, pharmacists, nutritionists, educators, administrators and unit representatives. An initial meeting was developed to determine opportunities for improvement and develop strategies to improve performance in glycemic control.

Hyperglycemia was rampant and common in many patient populations at the facility. The open-heart surgery unit CVRR was the only unit that had clinical strategies for glycemic control. While the nurses in CVRR were accustomed to glycemic control and IV insulin infusion, the protocol had not been updated in years and needed further revisions to current standards. The hospitalwide physician orders for intermittent subcutaneous sliding-scale insulin were also outdated and needed revisions to include the use of long-acting, basal insulin and the incorporation of rapid acting, analog insulin.

The institution did not have a policy or strategy to manage patients on insulin pumps, particularly during operative or procedural events. Education of nurses in the organization was variable, and with the advent of many new insulin and oral glycemic control medications, development of standardized and updated education was needed to avoid errors in insulin administration. Additionally, turnover of nursing staff, high numbers of nursing students and physician residents, and use of agency personnel yielded new groups of professionals entering the organization who required introduction to new glycemic control standards.

The SUGAR team established small working groups to develop specific changes in practice with clear timelines for dissemination throughout the organization. A uniform approach was designed to address elements needed for successful implementation: protocol and guideline development, education and strategies for pilot testing in a few units, followed by systemwide dissemination. Development teams were assimilated for each specific initiative.

Since the project began, the following best-practice designs were accomplished:. The reason for this approach was to streamline and provide a standard approach based upon the best scientific evidence available and to reduce variation in practice related to glycemic control. Each of these strategies for glycemic control was implemented in a systematic manner, driven by advanced practice nurses, physicians and nurse educators in specific practice areas.

All of these initiatives required presentation to appropriate committee meetings such that everyone was on board with the new initiatives, including specific practice committee groups, pharmacotherapy and therapeutics, physician leadership groups and collaborative practice teams. This involvement from key leaders in each area of practice was essential for buy-in and adoption of new strategies.