Multidisciplinary approach may overcome ICU barriers
Published clinical trials have demonstrated morbidity and mortality benefits of moderate-to-tight glycemic control in critically ill patients. Despite a growing body of evidence supporting use of this beneficial intervention, attaining such glucose control remains difficult. Research by Kevin Anger, PharmD, at Brigham and Women's Hospital pharmacy department in Boston, has found that health care providers face many potential barriers to providing optimal glycemic control in their ICUs. Developing strategies to overcome identified barriers is essential to ensure glycemic control and improve patient outcomes.
Barriers to ICU glucose control, Anger says, include the role of different health professionals in glucose management, communication among health care professionals, guidelines, protocols, ICU culture, fear of hypoglycemia, glucose monitoring, education, systems analysis, health care resources, nutritional needs, and drug utilization. "By ensuring compliance, changing ICU culture, developing guidelines and protocols, and incorporating a multidisciplinary approach, clinicians can achieve glycemic control in the critically ill population and improve patient outcomes," Anger says.
According to Anger, a multidisciplinary approach to patient care can lead to improved outcomes in critically ill patients and failure to integrate these services is a potential barrier to glucose control and quality of patient care. "Evaluating the characteristics of the ICU can be used to clearly define roles of health care professionals in patient glucose management," he wrote. "Improving glucose control may involve the use of clinical pathways, clinical practice guidelines, and decision support tools that use the services and specialized knowledge of all professions practicing in the ICU. By developing clinical care pathways, a 'road map' of care is developed that outlines the responsibilities of each provider in managing patient glucose levels. A road map of care will define who starts the treatment, writes patient-specific orders, monitors therapy, and adjusts pharmacologic and dietary interventions. Clinical care pathways should incorporate a multidisciplinary approach to glycemic control that facilitates communication, goal-setting, and feedback, all with the goal of improving patient outcomes."
First, understand facility's culture, resources
Anger says clinicians must understand the culture and resources of their facility before developing and implementing glucose control protocols. Protocols should eliminate reliance on one service to drive the protocol. Development of a seamless institutionwide protocol, with systems in place that reduce decision-making and increase multidisciplinary support, can improve ICU glucose control and patient outcomes.
With only 50-75% of Americans receiving the standard of care recommended by established guidelines, failure to begin insulin therapy creates an obvious barrier to controlling glucose in critically ill patients. Glucose control protocols won't improve patient outcomes if they aren't used, Anger notes. Implementation of glucose control procedures that specify the roles of physicians, nurses, pharmacists, and nutritionists in controlling glucose concentrations must fit in the institution's culture to ensure efficacy, safety, and compliance.
Inadequate communication among health care professionals in the ICU can create another barrier to achieving glucose control in critically ill patients, Anger says. While a multidisciplinary approach to patient care can improve patient outcomes, communication problems among clinicians can lead to inadequate glucose control. And worsened patient outcomes may be attributed to poor communication, teamwork, understanding of shared goals, and problem-solving skills among ICU staff.
Developing ICU glucose control pathways that facilitate and ensure communication among health care providers is essential for providing optimal treatment, according to Anger. Both dietary and pharmacologic interventions must be communicated to all clinicians participating in patient care. Easy access to information in the form of computerized physician order entry, the electronic drug administration record, point-of-care testing, and daily multidisciplinary rounds allow clinicians to share information and optimize glucose control interventions.
Protocols necessary for success
Anger's research also found that implementation of ICU glucose control protocols is essential to achieving tight glucose control there. "Advantages of protocol use," he says, "include more consistent glucose control, reduced trial and error patterns with intravenous insulin, ability to maintain blood glucose concentrations within the desired range, and earlier treatment of hypoglycemic events. And failing to implement intravenous insulin protocols raises a major barrier to controlling glucose concentrations in critically ill patients."
He notes that the American College of Endo-crinology and the American Diabetes Association recommend target blood glucose concentrations of 80-110 mg/dL in critically ill patients. Several ICU glucose control protocols are in published literature, but few have been subjected to efficacy, safety, and logistic analysis. Anger says institutions should evaluate the ability of their ICU glucose control protocols to achieve recommended target blood glucose concentrations and to maintain safety. Institutions seeking to implement new protocols are faced with the challenge of incorporating protocols published in the literature or developing and testing their own protocol.
To achieve practice changes, Anger says, it is necessary for one or more clinicians to become "physical champion" and be the driving force for implementing the change. Someone who would be a physical champion is willing to devote the time, conduct the research, and gather the resources needed to guide and implement a change in practice.
"Physical champions consist of physicians, nurses, pharmacists, and nutritionists who are willing to undertake the long and tedious process of changing glucose control practice in the ICU," Anger says. "Physical champions must develop skills in analyzing literature, conducting research, drafting guidelines, and political lobbying. Successful physical champions must have a comprehensive understanding of and a detailed plan to overcome the many barriers to ICU glucose control. Changing practice within the institutional setting requires knowledge of sociopolitical, professional, patient, intraprovider, and practice-based factors that influence guideline implementation. The physical champion serves as the organizer of the cascade of events needed to implement ICU glucose control guidelines."
[Editor's note: Contact Dr. Anger at (617) 732-5500.]
Published clinical trials have demonstrated morbidity and mortality benefits of moderate-to-tight glycemic control in critically ill patients. Despite a growing body of evidence supporting use of this beneficial intervention, attaining such glucose control remains difficult.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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