Strict Glycemic Control: Pilot Observations on Emergency Department Implementation

2.50
Hdl Handle:
http://hdl.handle.net/10755/162676
Type:
Presentation
Title:
Strict Glycemic Control: Pilot Observations on Emergency Department Implementation
Abstract:
Strict Glycemic Control: Pilot Observations on Emergency Department Implementation
Conference Sponsor:Emergency Nurses Association
Conference Year:2007
Author:Storer, Andrew, CRNP, MSN
P.I. Institution Name:Temple University-Department of Emergency Medicine
Title:Specialty Nurse Coordinator, Department of Emergency Medicine, Adjunct Clinical Instructor, Department of Nursing
Contact Address:3401 N. Broad Street, 1007 Jones Hall,, Philadelphia, PA, 19140, USA
Contact Telephone:(215) 370-6402
Co-Authors: Nina T. Gentile, MD; Hannah Reimer, RN, BSN
[Research Paper Presentation] Purpose: Mortality among patients with critical illness exceeds 20% with most deaths attributable to sepsis and multisystem organ failure. Hyperglycemia is common in critically ill patients. Maintaining normoglycemia with insulin in the ICU setting has been shown to improve neurologic, cardiovascular, and infectious outcomes. Earlier control of blood glucose (BG) using an insulin infusion protocol in the emergency department (ED) may further improve short and long term clinical outcomes. The purpose of this project was to establish the feasibility and safety of using an insulin infusion protocol to achieve and maintain strict glycemic control for at least six hours in a heterogeneous group of critically ill patients in the emergency department.

Design: Pilot prospective observational study.

Setting: This study was conducted in a 35-bed emergency department of an urban teaching Level I trauma center.

Sample: Patients with BG level = 130mg/dL and 1) acute physiology and chronic health evaluation (APACHE) II score = 9, or 2) > two systemic inflammatory response syndrome (SIRS) criteria with lactate = 4 or systolic blood pressure (SBP) < 90mmHg despite one liter of fluid, or 3) evidence of end organ dysfunction were included. Those requiring urgent interventional procedures or surgery outside the emergency department were excluded.

Methodology: Insulin (Novolin Regular) was titrated by protocol by ED clinical research nurses to achieve glycemic control, BG levels between 80 and 110 mg/dL for at least 30 minutes while in ED. Measurements included 1) time to target range, 2) consecutive BG values between 80 mg/dL and 110mg/dL 15 minutes apart, 3) incidence and duration of hypoglycemia [(BG <80 and >60mg/dL (mild); <60 mg/dL and >40 mg/dL (moderate); <40mg/dL or any change in mental status (severe)] during six hours to achieve and maintain BG in target range.

Results: Fifteen patients were included. The average APACHE II score was 15.5 and mean initial BG level was 247.9mg/dL. 67% of the patients had pre-existing diabetes (n = 10) and 33% (n = 5) did not. Enrolled patients had an average lactate of 3.6mmol/liter. The average time to achieving a BG of = 110 mg/dL was 160 minutes. Maintenance of target glucose ranges took 206.5 minutes to achieve, on average. Over the six-hour study period, six patients developed mild hypoglycemia that lasted an average of 55 minutes. There were no episodes of severe hypoglycemia.

Conclusions: This study demonstrated that glycemic control using an insulin infusion protocol is effective, feasible, and safe. Future research efforts will focus on clinical outcomes, emergency department, and intensive care unit length of stay and on healthcare economics. Emergency nurses are at the forefront of having the ability to assess and intervene to improve patient outcomes. Emergency nurses have the direct ability to prevent recidivism, educate patients regarding ongoing glycemic control, and impact patients overall health status.
Repository Posting Date:
27-Oct-2011
Date of Publication:
17-Oct-2011
Sponsors:
Emergency Nurses Association

Full metadata record

DC FieldValue Language
dc.typePresentationen_GB
dc.titleStrict Glycemic Control: Pilot Observations on Emergency Department Implementationen_GB
dc.identifier.urihttp://hdl.handle.net/10755/162676-
dc.description.abstract<table><tr><td colspan="2" class="item-title">Strict Glycemic Control: Pilot Observations on Emergency Department Implementation</td></tr><tr class="item-sponsor"><td class="label">Conference Sponsor:</td><td class="value">Emergency Nurses Association</td></tr><tr class="item-year"><td class="label">Conference Year:</td><td class="value">2007</td></tr><tr class="item-author"><td class="label">Author:</td><td class="value">Storer, Andrew, CRNP, MSN</td></tr><tr class="item-institute"><td class="label">P.I. Institution Name:</td><td class="value">Temple University-Department of Emergency Medicine</td></tr><tr class="item-author-title"><td class="label">Title:</td><td class="value">Specialty Nurse Coordinator, Department of Emergency Medicine, Adjunct Clinical Instructor, Department of Nursing<br/></td></tr><tr class="item-address"><td class="label">Contact Address:</td><td class="value">3401 N. Broad Street, 1007 Jones Hall,, Philadelphia, PA, 19140, USA</td></tr><tr class="item-phone"><td class="label">Contact Telephone:</td><td class="value">(215) 370-6402</td></tr><tr class="item-email"><td class="label">Email:</td><td class="value">astorer@temple.edu</td></tr><tr class="item-co-authors"><td class="label">Co-Authors:</td><td class="value"> Nina T. Gentile, MD; Hannah Reimer, RN, BSN</td></tr><tr><td colspan="2" class="item-abstract">[Research Paper Presentation] Purpose: Mortality among patients with critical illness exceeds 20% with most deaths attributable to sepsis and multisystem organ failure. Hyperglycemia is common in critically ill patients. Maintaining normoglycemia with insulin in the ICU setting has been shown to improve neurologic, cardiovascular, and infectious outcomes. Earlier control of blood glucose (BG) using an insulin infusion protocol in the emergency department (ED) may further improve short and long term clinical outcomes. The purpose of this project was to establish the feasibility and safety of using an insulin infusion protocol to achieve and maintain strict glycemic control for at least six hours in a heterogeneous group of critically ill patients in the emergency department.<br/><br/>Design: Pilot prospective observational study.<br/><br/>Setting: This study was conducted in a 35-bed emergency department of an urban teaching Level I trauma center.<br/><br/>Sample: Patients with BG level = 130mg/dL and 1) acute physiology and chronic health evaluation (APACHE) II score = 9, or 2) &gt; two systemic inflammatory response syndrome (SIRS) criteria with lactate = 4 or systolic blood pressure (SBP) &lt; 90mmHg despite one liter of fluid, or 3) evidence of end organ dysfunction were included. Those requiring urgent interventional procedures or surgery outside the emergency department were excluded.<br/><br/>Methodology: Insulin (Novolin Regular) was titrated by protocol by ED clinical research nurses to achieve glycemic control, BG levels between 80 and 110 mg/dL for at least 30 minutes while in ED. Measurements included 1) time to target range, 2) consecutive BG values between 80 mg/dL and 110mg/dL 15 minutes apart, 3) incidence and duration of hypoglycemia [(BG &lt;80 and &gt;60mg/dL (mild); &lt;60 mg/dL and &gt;40 mg/dL (moderate); &lt;40mg/dL or any change in mental status (severe)] during six hours to achieve and maintain BG in target range.<br/><br/>Results: Fifteen patients were included. The average APACHE II score was 15.5 and mean initial BG level was 247.9mg/dL. 67% of the patients had pre-existing diabetes (n = 10) and 33% (n = 5) did not. Enrolled patients had an average lactate of 3.6mmol/liter. The average time to achieving a BG of = 110 mg/dL was 160 minutes. Maintenance of target glucose ranges took 206.5 minutes to achieve, on average. Over the six-hour study period, six patients developed mild hypoglycemia that lasted an average of 55 minutes. There were no episodes of severe hypoglycemia.<br/><br/>Conclusions: This study demonstrated that glycemic control using an insulin infusion protocol is effective, feasible, and safe. Future research efforts will focus on clinical outcomes, emergency department, and intensive care unit length of stay and on healthcare economics. Emergency nurses are at the forefront of having the ability to assess and intervene to improve patient outcomes. Emergency nurses have the direct ability to prevent recidivism, educate patients regarding ongoing glycemic control, and impact patients overall health status.</td></tr></table>en_GB
dc.date.available2011-10-27T10:32:15Z-
dc.date.issued2011-10-17en_GB
dc.date.accessioned2011-10-27T10:32:15Z-
dc.description.sponsorshipEmergency Nurses Associationen_GB
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