Improving Blood Glucose Monitoring in the ICU

•• Bonnie Castonguay RNBonnie Castonguay RN•• Shobha Satsangi, RPh. MS Shobha Satsangi, RPh. MS •• Melinda Ashton, MDMelinda Ashton, MD

Improving Blood Improving Blood Glucose Monitoring Glucose Monitoring

in the ICUin the ICU

Team MembersTeam Members•• Bonnie Castonguay RNBonnie Castonguay RN•• Shobha Satsangi, RPh, Shobha Satsangi, RPh,

MS, University of UtahMS, University of Utah•• Melinda Ashton, M.D.Melinda Ashton, M.D.•• Joe Vierra, M.D.Joe Vierra, M.D.•• Kevin Hara, M.D.Kevin Hara, M.D.•• Tad Jackson, M.D.Tad Jackson, M.D.•• Cathy Adams, R.N.Cathy Adams, R.N.•• Cheryl Kozai, R.N.Cheryl Kozai, R.N.•• Stevee Sadama, R.N.Stevee Sadama, R.N.•• Pauline Doucet, R.N.Pauline Doucet, R.N.•• Jen Chahanovich, R.R.T.Jen Chahanovich, R.R.T.

Hawaii Pacific HealthHawaii Pacific Health

•• 4 acute care hospitals 4 acute care hospitals (2 years after merger)(2 years after merger)

•• 5 adult ICUs5 adult ICUs3 ICUs managed 3 ICUs managed

by the same by the same intensivistsintensivists

•• No shared evidence No shared evidence based protocolsbased protocols

Why blood glucose Why blood glucose management? management?

•• Tight control of hyperglycemia in Tight control of hyperglycemia in hospitalized patients helps reduce hospitalized patients helps reduce morbidity and mortalitymorbidity and mortality

-- clear evidence in diabeticsclear evidence in diabetics-- clear evidence in CV surgery ptsclear evidence in CV surgery pts-- growing evidence in all patientsgrowing evidence in all patients

Why Blood glucose management?Why Blood glucose management?

•• It was “on the list” of issues our intensivists It was “on the list” of issues our intensivists wanted to addresswanted to address

What is the current status of What is the current status of monitoring blood glucose in our monitoring blood glucose in our

ICUs?ICUs?

•• It is done when initiated by the It is done when initiated by the physician as he or she remembersphysician as he or she remembers

•• Routinely measured and managed in the Routinely measured and managed in the CV surgical patientsCV surgical patients

Study ObjectiveStudy Objective

To measure the blood glucose levels of To measure the blood glucose levels of acute care ICU patients in all adult ICUs in acute care ICU patients in all adult ICUs in Hawaii Pacific Health hospitals on a Hawaii Pacific Health hospitals on a regular basis during the first few days of regular basis during the first few days of an ICU admission. an ICU admission.

Objectives Expanded Objectives Expanded

We wanted to create a collaborative working We wanted to create a collaborative working group of ICU nurses and physicians to group of ICU nurses and physicians to evaluate and implement evidence based evaluate and implement evidence based protocols for care of our adult ICU patients protocols for care of our adult ICU patients in all of our ICUsin all of our ICUs

Aim StatementAim StatementTo gain >90% compliance with blood To gain >90% compliance with blood glucose monitoring from 2.81 per 24 hours glucose monitoring from 2.81 per 24 hours to at least 4 times per 24 hour period for to at least 4 times per 24 hour period for the first three days of the ICU stay in all the first three days of the ICU stay in all newly admitted ICU patients of the newly admitted ICU patients of the participating physicians within two months participating physicians within two months of implementation.of implementation.

HypothesesHypotheses

1. If a team of ICU caregivers (who don1. If a team of ICU caregivers (who don’’t t usually work together) are able to usually work together) are able to recommend standardized blood glucose recommend standardized blood glucose monitoring frequency for their acute ICU monitoring frequency for their acute ICU patients, then routine blood glucose patients, then routine blood glucose monitoring will become standard practice.monitoring will become standard practice.


2. If the team agrees to standardized blood 2. If the team agrees to standardized blood glucose monitoring, then they will find glucose monitoring, then they will find ways to incorporate the practice into their ways to incorporate the practice into their daily work flow.daily work flow.


3.If the team regularly monitors blood 3.If the team regularly monitors blood glucose levels in their acute ICU patients, glucose levels in their acute ICU patients, they will begin to recognize the need for they will begin to recognize the need for standardized management of standardized management of hyperglycemia.hyperglycemia.


4. If a team of ICU caregivers who don4. If a team of ICU caregivers who don’’t t work together have a successful work together have a successful experience with this project, then they experience with this project, then they will be more likely to work together on will be more likely to work together on additional ICU protocols.additional ICU protocols.

Conceptual modelConceptual model

VentilatorManagement Fluid Management Physiology

ManagementTherapeutic

Management

Assessment

Diagnostic

Treatment

ContinuingPlanning

Laboratory

Radiology

Artery Lines

Vital Signs

Blood glucose

Define Frequency

Phlebotomy

Respiratory Glucose levelReport

Intensive Care Management

Non-Diabetic

Diabetic

Document level ondesignated form

Glucose >150or < 60

Diabeticmanagement

Where we startedWhere we started--baselinebaseline

2.772.771.771.7753531471473030StraubStraub

2.902.901.401.4042421221223030WCWC

2.782.783.233.231001002722723131PMPM

Mean Mean BS/pt dayBS/pt day

Mean Mean days/ptdays/pt

#pt days #pt days with BSwith BS

#BS #BS donedone

#Pts#PtsHospHosp

Data source: Point of care test reports and chart review

Our implementation planOur implementation plan•• Medical Directors and hospitalists will Medical Directors and hospitalists will

order blood sugar monitoring order blood sugar monitoring

•• Nurses will track blood sugar on the daily Nurses will track blood sugar on the daily monitoring form monitoring form

•• Tracking form created to provide a visual Tracking form created to provide a visual display of blood sugar results over timedisplay of blood sugar results over time

Blood Sugar Daily Monitoring Blood Sugar Daily Monitoring FormForm

Blood sugar Daily Monitoring formBlood sugar Daily Monitoring form AddressographAddressograph

Date Admit:____________Date Admit:____________

** Blood sugar monitoring will be performed regularly for the firstBlood sugar monitoring will be performed regularly for the first three days of a three days of a patientspatients’’ staystay

* * Regular monitoring will be defined as four (4) times a day and aRegular monitoring will be defined as four (4) times a day and at least four (4) t least four (4) hours apart.hours apart.

BloodBloodSugarSugarResultResult

TimeTimeBloodBloodSugarSugarTestedTested







Date Date

Blood Sugar Tracking FormBlood Sugar Tracking FormBlood Sugar Tracking FormBlood Sugar Tracking Form AddressographAddressograph

Patient is a diabetic: Y___ N____Patient is a diabetic: Y___ N____Patient is on insulin: Y___ N____Patient is on insulin: Y___ N____Admit date________Admit date________Admit time________Admit time________

020406080

100120140160180200220240260280300

2 4 6 8 10 12 14 16 18 20 22 24 2 4 6 8 10 12 14 16 18 20 22 24 2 4 6 8 10 12 14 16 18 20 22 24

Day 1 Day 2 Day 3

Study Sample Study Sample

•• All of the ICU patients cared for by the All of the ICU patients cared for by the physicians who agreed to participate and physicians who agreed to participate and were listed as team members for this were listed as team members for this project.project.

Sample Patient #1Sample Patient #1BS rangesBS ranges

020406080

100120140160180200220240260280300

2 4 6 8 10 12 14 16 18 20 22 24 2 4 6 8 10 12 14 16 18 20 22 24 2 4 6 8 10 12 14 16 18 20 22 24

Day 1 Day 2 Day 3

Sample Patient #2Sample Patient #2BS rangesBS ranges

020406080

100120140160180200220240260280300

2 4 6 8 10 12 14 16 18 20 22 24 2 4 6 8 10 12 14 16 18 20 22 24 2 4 6 8 10 12 14 16 18 20 22 24

Day 1 Day 2 Day 3

What was our impact?What was our impact?Mean Blood Sugar Checks per Patient Day

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

Baseline Post-Implementation

Phase

Pali MomiStraubWomen & Children

What was our impact?What was our impact?

Mean Blood Sugar Checks per Patient Day

0.0

1.0

2.0

3.0

4.0

5.0

6.0


Excl First Day


What was our impact?What was our impact?Mean Blood Sugar Checks per Patient Day

0.0

1.0

2.0

3.0

4.0

5.0

6.0


Excl First & LastDays

Study Phase


Blood Sugar Levels

020

406080

100

120140160180

200220240260

280300

Day 1 Day 2 Day 3

PMWCStraub

What did we learn?What did we learn?

•• Intensivists were already aware of the Intensivists were already aware of the issue….it was “on the list”issue….it was “on the list”

•• They did not have the time to design a They did not have the time to design a projectproject

•• Collaboration was not a problemCollaboration was not a problem•• They were anxious to provide improved They were anxious to provide improved

carecare

What did we learn? What did we learn?

•• Ordering blood sugars and documenting Ordering blood sugars and documenting times and results were not part of the times and results were not part of the physician or nurses current work processphysician or nurses current work process

•• Change is not easyChange is not easy

•• # of participating physicians small# of participating physicians small

Next StepsNext Steps-- Work in ProgressWork in Progress

•• Choose a blood glucose management Choose a blood glucose management protocolprotocol

•• Determine the desired range of blood Determine the desired range of blood glucose for our patients glucose for our patients

•• Adopt a blood glucose measurement Adopt a blood glucose measurement flow sheet for use at the bedside in our flow sheet for use at the bedside in our ICU’sICU’s

Work in ProgressWork in Progress

•• Pilot the chosen blood glucose Pilot the chosen blood glucose management protocols and guidelines management protocols and guidelines among the same group of physicians as among the same group of physicians as the measurement pilotthe measurement pilot

•• Finally, include Finally, include all ICU patients at all HPH all ICU patients at all HPH adult ICUs once the protocol found to be adult ICUs once the protocol found to be acceptable by the initial groupacceptable by the initial group

Work in ProgressWork in Progress

•• Look at other protocols for care of our ICU Look at other protocols for care of our ICU populations as prioritized by our ICU care populations as prioritized by our ICU care providersproviders

Questions ?Questions ?

Improving Blood Glucose Monitoring in the ICU

Documents