EBP REPORT- TEAM OUTLAW

By Susan Outlaw, Melissa Ashley, Mary Holston, & Beverly McMilionOctober 17, 2013

Project Overview

• Introduction

• Patient/Situation Focused

Question

• Target Resources/Evidence

• Relevance of Evidence

• Evidence Appraisal

• Action/Implementation and

Evaluation

• Conclusion

Introduction

Diabetes Mellitus

• Type I (IDDM)

Diagnosed in childhood

Autoimmune destruction of beta cells

Treatment is Insulin replacement therapy, diet & exercise

Symptoms include polyuria, polydipsia, polyphagia, weight loss, fatigue

• Type II (NIDDM)

Usually diagnosed in adults

Treatment may or may not include insulin, other medications, diet and exercise

Symptoms include polydipsia, polyphagia, polyuria, blurred vision, slow healing wounds, & weight loss

Case Study

The case study involves Amy, a 36 year old Caucasian female,

admitted to the hospital and placed on an insulin drip due to

her blood sugar of 300. Amy is an overweight smoker, a

heavy drinker, and is nonadherent to her home insulin

regimen. The hospital insulin drip protocol is to maintain

serum blood sugar between 70 and 110 mg/dl. Recently a

pilot research project indicated that a mean serum blood

sugar for patients discharged from cardiac care units was

148. The nurses caring for Amy question if the current

protocol ranges are appropriate.

Focused Question

What is the highest level of evidence

available in determining if the hospital’s

current insulin drip protocol to maintain

serum blood glucose levels between 70

and 110 mg/dl is effective for a 36 year old

Caucasian female who is an overweight

smoker, heavy drinker, and non-adherent

to her home insulin regimen and has been

admitted to the hospital with blood sugar

of 300 and placed on an insulin drip?

Medline

Google Scholar

PubMed

CINAHL

Cochrane

Targeted Resources

LEVEL OF EVIDENCE

Highest available evidence

Alternative Search Words

Meta-analysis

Systematic reviews

Peer reviewed

Random control trials

PPAARE QUESTION FOR CASE STUDY FOCUSED QUERY QUESTION

P• PROBLEM

P• PATIENT

A• ACTION

A• ALTERNATIVE

R• PATIENT RESULTS

E• LEVEL OF EVIDENCE

PROBLEM

Is the hospital insulin drip protocol effective for the patient?

Alternative search words

Efficacy of insulin protocol

Diabetes Treatment

PATIENT

Middle Aged

Female

Diabetic

Smoker

Caucasian

Over weight

Non-adherent

Heavy Drinke

r

Blood sugar of 300

Relevant Evidence

• The highest level of evidence from numerous research designs such as meta-analysis, quantitative,

qualitative, and Random Control Trials were utilized to determine and evaluate literature and

identify the safety and efficacy of insulin infusion therapy for a defined glycemic range.

• Population included adult medical/surgical and critical care patients receiving Continuous Insulin

Infusion.. Exclusions were children, other hypoglycemic and anti-diabetic drugs.

• Data collection methods included clinical questions to analyze data base searches, clinical variables

and Acute Physiology and Chronic Health Evaluation II (APACHE II), clinical interventions from

patient charts, nursing records, and in-depth interviews transcribed using Ground Theory

Approach.

• Data analysis methods utilized were tape recorded transcribed Maxqda 2007 in 3 phases of coding

per review, blood glucose values of patients were compared using the Student’s t test and Wilcoxon

rank-sum test, and retrospective analysis of 200 consecutive patients receiving CII.

ACTIONS

Maintain realistic blood glucose control while in hospital

Alternative Search Words

Blood glucose monitoring

Hyperglycemia

Insulin

Glycemic control

ALTERNATIVE

None

PATIENT RESULTS

Establish individualized blood glucose protocol to achieve optimal outcome

Alternative Search Words

Effective blood sugar control

Optimal outcomes Decrease

complications Perceptions Experiences

COURSE OF ACTION• Adopt a new insulin drip protocol to maintain serum blood glucose

levels between 110 and 150 mg/dl.

• Establishing a written protocol of referrals for patients on insulin

infusion

• Discharge planning and education to begin on day one of

hospitalization

• Monitor, evaluate and review blood glucose levels on patients

receiving insulin infusion, t mortality, and hospital readmit rates in

this patient population to evaluate effectiveness of newly established

protocol

CONCLUSION• Tight glycemic control (target of 80-110 mg/dL) in

ICU has increased risk of severe hypoglycemia

• The ADA/AACE Inpatient Task Force now

recommends against tight glycemic control (80-110

mg/dL) for patients in the ICU and suggests new

glycemic targets (140-180 mg/dl) are more

reasonable, achievable, and safer in patients

receiving CII in the ICU setting.

REFERENCES

Adams, M. P., Holland, N., & Urban, C. (2014). Pharmacology for nurses: A pathophysiologic approach (4th ed.). Boston: Pearson.

Bailey, V., Dziura, J., Goldberg, P., Halickman, J., Inzucchi, S., Lee, M., Lee, S., Sherman, R., & Siegel, M. (2004). Implementation of a safe

and effective insulin infusion protocol in a medical intensive care unit. Diabetes Care, 27(2), 461-467. doi: 10.2337/diacare 27.2461.

Retrieved from: http://care.diabetesjournals.org/content/27/2/461.long

Bilo, H.J.G., Hortensius, J., Jaap, J., Kars, M.C., Kleefstra, N., & Wierenga, W. S. (2012). Perspectives of patients with type 1 or insulin-

treated type 2 diabetes on self-monitoring of blood glucose: A qualitative study. BioMed Central Public Health, 12:167. doi: 10.1186/1471-

2458-12-167. Retrieved from: http://www.biomedcentral.com/1471-2458/12/167

Jacobi, J., Bircher, N., Krinsley, J., Agus, M., Braithwaite, S., Deutschman, C., … Schunemann, H. (2012). Guidelines for the use of an insulin

infusion for the management of hyperglycemia in critically ill patients. Critical Care Medicine, 40(12), 3251-3276. DOI:

10.1097/CCM.0b013e3182653269. Retrieved from: http://www.learnicu.org/SiteCollectionDocuments/Glycemic_Control.pdf

Smiley, D., Rhee, M., Limin, P., Roediger, L., Mulligan, P., Satterwhite, L.,…Umpierrez, G. (2010). Safety and efficacy of continuous insulin

infusion in noncritical care settings. Journal of Hospital Medicine: An official publication of the society of hospital medicine. 5(4), 212-217.

doi: 10.1002/jhm.646 Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/2039402

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