Abstract
BackgroundTight glucose control by intensive insulin therapy has become a key part of critical care and is an important field of study in acute coronary care. A balance has to be found between frequency of measurements and the risk of hypoglycemia. Current nurse-driven protocols are paper-based and, therefore, rely on simple rules. For safety and efficiency a computer decision support system that employs complex logic may be superior to paper protocols.MethodsWe designed and implemented GRIP, a stand-alone Java computer program. Our implementation of GRIP will be released as free software. Blood glucose values measured by a point-of-care analyzer were automatically retrieved from the central laboratory database. Additional clinical information was asked from the nurse and the program subsequently advised a new insulin pump rate and glucose sampling interval.ResultsImplementation of the computer program was uneventful and successful. GRIP treated 179 patients for a total of 957 patient-days. Severe hypoglycemia (< 2.2 mmol/L) only occurred once due to human error. With a median (IQR) of 4.9 (4.2 – 6.2) glucose measurements per day the median percentage of time in which glucose fell in the target range was 78%. Nurses rated the program as easy to work with and as an improvement over the preceding paper protocol. They reported no increase in time spent on glucose control.ConclusionA computer driven protocol is a safe and effective means of glucose control at a surgical ICU. Future improvements in the recommendation algorithm may further improve safety and efficiency.
Highlights
Tight glucose control by intensive insulin therapy has become a key part of critical care and is an important field of study in acute coronary care
The association between stress hyperglycemia and adverse outcome has been observed in numerous patient categories, ranging from patients admitted to the general ward [2] to myocardial infarction [3] and stroke patients [4]
Because coronary care units (CCU) are a less controlled environment with a lower personnel-topatient ratio than intensive care unit (ICU), intensive insulin therapy is hard to achieve with paper protocols [14]
Summary
Tight glucose control by intensive insulin therapy has become a key part of critical care and is an important field of study in acute coronary care. Several studies have evaluated glucose-related therapies as strategies to improve outcome in acute coronary syndromes, such as high dose glucose-insulin-potassium (GIK) infusion [11,12], or combined glucoseinsulin infusion to reduce glucose levels [13,14]. Clinical results have been mixed, with most recent results being negative, the efficacy of glucose-lowering interventions in acute coronary care is still unknown since none of the published trials achieved tight glycemic control [11,14]. Because coronary care units (CCU) are a less controlled environment with a lower personnel-topatient ratio than ICUs, intensive insulin therapy is hard to achieve with paper protocols [14]. An optimized decision making algorithm might be able to make tighter control possible
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