Performance improvement measures in achieving glycemic control in the acute brain injury population.(CE)(Report)

ABSTRACT

Glycemic control is becoming a standard practice in the intensive care environment because it has been shown to produce positive patient outcomes and benefits. A 14-bed neurointensive care unit initiated a strict glycemic protocol and evaluated the results over a 1-year period through a performance improvement initiative. Results indicated that tight glycemic control could be achieved safely by adhering to an evidence-based established protocol. The average blood glucose level for all patients was between 90 and 130 mg/dl by Day 2 after the implementation of the glycemic control protocol. The purpose of this article was to explain how a strict glycemic protocol was safely implemented. Further research is necessary to determine long-term benefits of glycemic control in the population with neurocritical illness.

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Glycemic control has become a growing trend in inpatient treatment and clinical research. Hyperglycemia has been identified as a frequent concurrent diagnosis in those with critical illness, even for those without a past medical history significant for diabetes mellitus. More often, hyperglycemia is being recognized as an independent risk factor potentially leading to further complications in both surgical and medical patient populations (Ellger et al., 2006). This phenomenon has evolved into a significant issue among the critical brain injury population, despite the patient's age, gender, race, past medical history, and state of health before injury. Research has shown that early intervention in glycemic control improves clinical outcome in the population with critical illness in both medically and surgically treated patients by reducing morbidity and mortality rates, infection rates, critical illness polyneuropathy, myopathy, the amount of time spent on mechanical ventilation, myocardial dysfunction, seizures, impaired recovery of organ failure, and neuromuscular dysfunction while improving wound healing (Ellger et al., 2006; Gearhart & Parbhoo, 2006; Hermans et al., 2007; Presutti & Millo, 2006).

Hepatic and peripheral insulin resistance and related insulin deficiency caused by a minute compensatory mechanism of pancreatic B cells have been shown to cause hyperglycemia in the population with critical illness, independent of the underlying disease process (Ellger et al., 2006). Glucose has been associated with brain tissue acidosis in patients who have experienced a major head injury (Zygun et al., 2004). Conditions such as diuresis, dehydration, ketonemia, electrolyte imbalance, and changes in mental status have been associated with acute hyperglycemia. Impaired immune responses to injuries and infections, impaired gastrointestinal motility, high cardiovascular tonus, impaired wound healing, and higher mortality rates are some of the pathologies that have been reported as consequences of hyperglycemia (Khoury, Klausner, Ben-Abraham, & Szold, 2004).

Furthermore, in patients who have sustained a traumatic brain injury, transient hyperglycemia has been shown to adversely affect cerebral energy metabolism when the blood glucose level is greater than 15 mmol/L. This increase is associated with a moderate increase in cerebral lactate levels (Diaz-Parejo et al., 2003). Diaz-Parejo et al. (2003) reported that transient moderate hyperglycemia did not in fact affect cerebral energy metabolism, as defined by a blood glucose concentration of 12 to 15 mmol/L. Acute or new hyperglycemia has been believed to occur in 5% to 30% of patients with critical illness due to the hormonal response to stress (Khoury et al., 2004).

This article describes the implementation of a glycemic control protocol, predicted upon evidenced-based research in a 14-bed neuroscience trauma surgical intensive care unit (NTSICU). The protocol was designed specifically for neurocritical care patients. The patient population cared for in the 14-bed NTSICU consisted of patients with various neurological diseases, traumatic brain injuries, subarachnoid hemorrhages, cerebral aneurysms, traumatic spinal cord injuries, strokes, brain tumors, and neurosurgical procedures, both emergent and planned. The patient population consisted of a mixed medical-surgical care environment. After a time allotted for data collection, an advanced practice nurse (APN) evaluated the performance of the staffs adherence to the newly developed glycemic control protocol. Implications for practice and recommendations for further research are discussed as well.