Asociación entre Glucemia inestable, tiempo de estancia y mortalidad de pacientes en estado críticos: Estudio de cohorte / Associação Entre Glicemia Instável, Tempo de Permanência e Mortalidade de Pacientes Críticos: Estudo de Coorte / Relationships between unstable Glycemia, Hospital Length Of Stay, and mortality In Critically Ill patients: A cohort study

Resumen Introducción: El control y la evaluación de los niveles glucémicos de pacientes en estado críticos es un desafío y una competencia del equipo de enfermería. Por lo que, determinar las consecuencias de esta durante la hospitalización es clave para evidenciar la importancia del oportuno manejo. Objetivo: Determinar la asociación entre la glucemia inestable (hiperglucemia e hipoglucemia), el resultado de la hospitalización y la duración de la estancia de los pacientes en una unidad de cuidados intensivos. Metodología: Estudio de cohorte prospectivo realizado con 62 pacientes a conveniencia en estado crítico entre marzo y julio de 2017. Se recogieron muestras diarias de sangre para medir la glucemia. Se evaluó la asociación de la glucemia inestable con la duración de la estancia y el resultado de la hospitalización mediante ji al cuadrado de Pearson. El valor de p<0.05 fue considerado significativo. Resultados: De las 62 personas participantes, 50 % eran hombres y 50 % mujeres. La edad media fue de 63.3 años (±21.4 años). La incidencia de glucemia inestable fue del 45.2 % y se asoció con una mayor duración de la estancia en la UCI (p<0.001) y una progresión a la muerte como resultado de la hospitalización (p=0.03). Conclusión: Entre quienes participaron, la glucemia inestable se asoció con una mayor duración de la estancia más prolongada y con progresión hacia la muerte, lo que refuerza la importancia de la actuación de enfermería para prevenir su aparición.

Resumo Introdução: O controle e avaliação dos níveis glicêmicos em pacientes críticos é um desafio e uma competência da equipe de enfermagem. Portanto, determinar as consequências da glicemia instável durante a hospitalização é chave para evidenciar a importância da gestão oportuna. Objetivo: Determinar a associação entre glicemia instável (hiperglicemia e hipoglicemia), os desfechos hospitalares e o tempo de permanência dos pacientes em uma unidade de terapia intensiva. Métodos: Um estudo de coorte prospectivo realizado com 62 pacientes a conveniência em estado crítico entre março e julho de 2017. Foram coletadas amostras diariamente de sangue para medir a glicemia. A associação entre a glicemia instável com o tempo de permanência e o desfecho da hospitalização foi avaliada pelo teste qui-quadrado de Pearson. O valor de p <0,05 foi considerado significativo. Resultados: Das 62 pessoas participantes, 50% eram homens e 50% mulheres. A idade média foi de 63,3 anos (±21,4 anos). A incidência de glicemia instável foi de 45,2% e se associou a um tempo de permanência mais prolongado na UTI (p <0,001) e uma progressão para óbito como desfecho da hospitalização (p = 0,03). Conclusão: Entre os participantes, a glicemia instável se associou a um tempo mais longo de permanência e com progressão para óbito, enfatizando a importância da actuação da equipe de enfermagem para prevenir sua ocorrência.

Abstract Introduction: The control and evaluation of glycemic levels in critically ill patients is a challenge and a responsibility of the nursing team; therefore, determining the consequences of this during hospitalization is key to demonstrate the importance of timely management. Objective: To determine the relationship between unstable glycemia (hyperglycemia and hypoglycemia), hospital length of stay, and the hospitalization outcome of patients in an Intensive Care Unit (ICU). Methods: A prospective cohort study conducted with 62 critically ill patients by convenience sampling between March and July 2017. Daily blood samples were collected to measure glycemia. The correlation of unstable glycemia with the hospital length of stay and the hospitalization outcome was assessed using Pearson's chi-square. A p-value <0.05 was considered significant. Results: Among the 62 patients, 50% were male and 50% were female. The mean age was 63.3 years (±21.4 years). The incidence of unstable glycemia was 45.2% and was associated with a longer ICU stay (p<0.001) and a progression to death as a hospitalization outcome (p=0.03). Conclusion: Among critically ill patients, unstable glycemia was associated with an extended hospital length of stay and a progression to death, emphasizing the importance of nursing intervention to prevent its occurrence.

Influence of Optimal Management of Hyperglycemia and Intensive Nursing on Blood Glucose Control Level and Complications in Patients with Postoperative Cerebral Hemorrhage.

Background: Cerebral hemorrhage, also known as hemorrhagic stroke, is a common clinical cerebrovascular disease, accounting for about 10%-30% of stroke, with high morbidity and mortality. Objective: To observe the effect of optimal management of hyperglycemia and intensive nursing on blood glucose control level and complications in patients with postoperative cerebral hemorrhage. Methods: One hundred and eight patients with postoperative cerebral hemorrhage comorbid with stress hyperglycemia admitted to our neurosurgery department from February 2019 to February 2022 were selected and divided into a general group of 54 cases and an optimized group of 54 cases by simple random method. The general group was managed with conventional care, while the optimized group developed optimized management of hyperglycemia for intensive care. The indexes related to blood glucose control, electrolytes, National Institutes of Health Stroke Scale (NIHSS) scores, Barthel Index (BI) scores, and time to achieve blood glucose standard, insulin pumping time, patient satisfaction, and prognosis were compared between the two groups. Results: Before intervention, there was no statistical significance in the comparison of blood glucose control-related indicators and electrolytes between the two groups (P > 0.05). After 7 d and 14 d of intervention, the fasting blood glucose and 2 h postprandial blood glucose in the two groups were lower than before, while K+ and Na+ were higher than before (P < 0.05). The blood glucose indexes at the same time point in the optimized group were found to be lower than those in the general group by statistical analysis, but electrolytes were not statistically significant when compared with the general group (P > 0.05). In the optimized group, the time to achieve blood glucose standard (6.59 ± 1.94) d and insulin pumping time (7.14 ± 1.89) d were shorter than those in the general group [(7.48 ± 2.12) d and (8.58 ± 2.14) d], insulin dosage (748.85 ± 63.61) U was less than that in the general group (923.54 ± 84.14) U, and the incidence of hypoglycemia (3.70%) was lower than that in the general group (16.67%), and the satisfaction rate (92.59%) was higher than that of the general group (77.78%), which was statistically significant (P < 0.05). Before intervention, there was no significant difference in NIHSS score and BI score between the two groups (P > 0.05). After 7 d and 14 d of intervention, the NIHSS scores of the two groups were lower than before, while the BI scores were higher than before, and the NIHSS scores of the optimized group at the same time point were all lower than those of the general group, and the BI scores were higher than those of the general group (P < 0.05). The incidence of pulmonary infection (11.11%) and rebleeding (7.41%) in the optimized group were lower than those in the general group (25.93% and 22.22%), while deep vein thrombosis, multiple organ dysfunction syndrome (MODS), and death within 28 d was not statistically significant when compared with the general group (P > 0.05). Conclusion: Optimal management of hyperglycemia and intensive nursing can effectively control the blood sugar level of patients after cerebral hemorrhage, reducing insulin dosage, and the occurrence of hypoglycemia, pulmonary infection, and rebleeding.

Addressing Hospital-Acquired Hypoglycemia.

BACKGROUND: Hospitalized patients who have diabetes often experience hospital-acquired hypoglycemia, a potentially serious adverse event; as a result, management of this condition has become an important quality of care indicator in the inpatient environment. A growing body of research and evidence-based clinical guidelines support proper timing of point of care (POC) blood glucose (BG) measurements, mealtime insulin administration, and meal delivery to reduce the incidence of both hypoglycemic and hyperglycemic events. Monitoring and improving the timing of these three patient care interventions are recognized as a crucial step in the safe and effective care of patients with diabetes. PURPOSE: The objective of the QI project was to improve the timing of mealtime insulin administration related to bedside BG monitoring and meal delivery for patients with diabetes who receive mealtime insulin; a secondary goal was to decrease the number of episodes of recurrent hypoglycemia. The overall strategy was to change staff members' approach to mealtime insulin management from a series of individual tasks to a process-oriented collaborative approach. METHODS: Nurses on the medical-surgical unit at one hospital within a large health system formed a QI team with staff members in information technology and food and nutrition services. The team implemented an eight-week QI pilot project (July 3 to August 26, 2017) using a multidisciplinary approach to coordinate between POC BG measurement, mealtime insulin administration, and meal delivery. RESULTS: More than two years after the hospital-wide rollout of the practice change, follow-up analysis has shown that, on both noncritical and critical care units, recurrent hypoglycemia has decreased. For example, comparing data obtained in a six-month period before the pilot project (November 2016 through April 2017) with the same six-month period in 2018 and 2019, more than a year after the pilot project, the percentage of patient stays (admissions) on noncritical care units in which there was a recurrence of hypoglycemia fell from 41.8% (of 1,162 total hospital admissions) to 35.1% (of 792 total hospital admissions); similarly, the percentage of patient stays on critical care units in which recurrent hypoglycemia occurred decreased from 36.8% to 22.8%. CONCLUSIONS: Findings suggest that ensuring a consistent 30-minute window between POC BG measurement and meal delivery enabled nursing staff to perform timely POC BG measurements and administer a more optimal mealtime insulin dose. Increasing interdisciplinary communication, collaboration, and awareness of best practice guidelines relating to proper mealtime insulin administration resulted in a sustained improvement in timing between POC BG measurements and mealtime insulin administration and between mealtime insulin administration and meal delivery.

Implantación de un programa para el manejo de la hiperglucemia en la hospitalización con la incorporación de la enfermera consultora / Implementation of an inpatient hyperglycemia management program incorporating a nurse consultant

INTRODUCCIÓN Y OBJETIVOS: La eficacia y seguridad de los protocolos de manejo de la hiperglucemia hospitalaria con pautas basal-bolo están ampliamente demostradas, pero su implementación es insuficiente. El objetivo del estudio fue valorar la implantación y determinar la eficacia y seguridad de un protocolo de manejo de la hiperglucemia hospitalaria basado en la terapia basal-bolo y la incorporación de una enfermera consultora. MATERIAL Y MÉTODOS: La evaluación se realizó en 10 unidades de hospitalización. Se revisaron retrospectivamente los datos durante la hospitalización y a los 90 días tras el alta de 400 pacientes postimplantación y 200 pacientes preimplantación del protocolo. El grado de satisfacción de los profesionales se valoró mediante un cuestionario a los 12 meses de la implantación. RESULTADOS: La proporción de pacientes con pauta basal-bolo en el ingreso fue superior en el grupo postimplantación (58% frente a 9%, p < 0,001). La media de las glucemias prepandiales y al acostarse durante el ingreso fue menor en el grupo postimplantación (164 ± 41mg/dl frente a 196 ± 50 mg/dl, p < 0,001). La proporción de pacientes con glucemias > 300 mg/dl fue menor (36,3% frente a 50,5%; p < 0,001) y con glucemias < 70 mg/dl fue superior (15% frente a 9%, p = 0,040) en el grupo postimplantación. La adición e intensificación de la insulina fue la principal modificación del tratamiento al alta y se observó reducción significativa de la HbA1c a los 3 meses del alta en la fase postimplantación (p = 0,04). La valoración del protocolo por parte de los profesionales fue de 4,5 en una escala de 1 a 5. CONCLUSIONES: La incorporación de una enfermera consultora experta en diabetes como elemento central del programa de manejo de la hiperglucemia consigue que la mayoría de los pacientes hospitalizados con hiperglucemia reciban tratamiento con una pauta basal-bolo y una mejora del control glucémico durante la hospitalización y tras el alta

BACKGROUND AND AIMS: The efficacy and safety of inpatient hyperglycemia management protocols using basal-bolus regimens have been widely demonstrated, but their implementation is insufficient. The aim of the study was to assess implementation and to establish the efficacy and safety of inpatient hyperglycemia management protocol based on a basal-bolus regimen and the incorporation of a nurse consultant. MATERIAL AND METHODS: Evaluation was performed at 10 hospital units. Data were retrospectively reviewed during hospital stay and 90 days after discharge in 400 patients after protocol implementation and 200 patients before implementation. The degree of satisfaction of professionals was assessed using a questionnaire 12 months after implementation. RESULTS: The proportion of patients with basal-bolus regimens upon admission was higher in the postimplementation group (58% vs. 9%, P < 0.001). Mean pre-prandial and bedtime blood glucose levels during admission were lower in the postimplementation group (164 ± 41 mg/L vs. 196 ± 50 mg/dL, P < 0.001). After implementation, there were less patients with blood glucose levels > 300 mg/dL (36.3% vs. 50.5%, P < 0.001) and more patients with values < 70mg/dL (15% vs. 9%, P = 0.040). Insulin addition and intensification was the main change in treatment at discharge, and a significant HbA1c reduction was seen three months after discharge in the postimplementation phase (P = 0.04). The professionals assigned the protocol a score of 4.5 on a 1 to 5 scale. CONCLUSIONS: Incorporation of a nurse consultant expert in diabetes as key component of a hyperglycemia management program ensures that a majority of patients admitted to hospital for hyperglycemia receive treatment with a basal-bolus regimen and improves blood glucose control during hospital stay and after discharge

Nurse-managed basal-bolus versus sliding-scale insulin regimen in subjects with hyperglycemia at admission for orthopedic surgery: a propensity score approach.

AIMS: A sliding-scale (SS) regimen is discouraged to correct hyperglycemia in hospital patients, but there is resistance to adoption of basal-bolus (BB) treatment in surgical units. We tested the feasibility and the effects of a nurse-based BB regimen in orthopedic surgery. METHODS: Following an intense training to implement a protocol amenable by nurses, a group of patients admitted with hyperglycemia in an orthopedic institute were prospectively followed according to a basal-bolus insulin regimen (BB, n = 80). They were compared with a hyperglycemic group eventually treated by sliding-scale insulin on demand (SS, n = 122). Diabetes was present in 196 cases. Metabolic control was assessed during the first 3 days of surgery; outcome data were tested by logistic regression, after adjusting for propensity score. RESULT: Average blood glucose and glucose variability were lower in BB versus SS (P < 0.001), in the presence of similar 3-day insulin doses. Complications were recorded in 68 cases (16.2% vs. 45.1% in BB and SS, respectively). BB regimen was associated with propensity-adjusted reduction in all adverse events [odds ratio (OR) 0.36; 95% confidence interval (CI) 0.17-0.76] and of systemic infections (OR 0.18; 95% CI 0.07-0.50) and with shorter hospital stay (8.8 ± SD 5.2 days vs. 12.5 ± 7.4; P < 0.01). The superiority of BB regimen was confirmed in the pair-matched analysis. CONCLUSIONS: The study proves the feasibility and the superiority of nurse-based BB versus SS treatment in metabolic control and on the risk of adverse events in orthopedic surgery patients with hyperglycemia.

Implementation of an inpatient hyperglycemia management program incorporating a nurse consultant. / Implantación de un programa para el manejo de la hiperglucemia en la hospitalización con la incorporación de la enfermera consultora.

BACKGROUND AND AIMS: The efficacy and safety of inpatient hyperglycemia management protocols using basal-bolus regimens have been widely demonstrated, but their implementation is insufficient. The aim of the study was to assess implementation and to establish the efficacy and safety of inpatient hyperglycemia management protocol based on a basal-bolus regimen and the incorporation of a nurse consultant. MATERIAL AND METHODS: Evaluation was performed at 10 hospital units. Data were retrospectively reviewed during hospital stay and 90 days after discharge in 400 patients after protocol implementation and 200 patients before implementation. The degree of satisfaction of professionals was assessed using a questionnaire 12 months after implementation. RESULTS: The proportion of patients with basal-bolus regimens upon admission was higher in the postimplementation group (58% vs. 9%, P<0.001). Mean pre-prandial and bedtime blood glucose levels during admission were lower in the postimplementation group (164±41mg/L vs. 196±50mg/dL, P<0.001). After implementation, there were less patients with blood glucose levels >300mg/dL (36.3% vs. 50.5%, P<0.001) and more patients with values <70mg/dL (15% vs. 9%, P=0.040). Insulin addition and intensification was the main change in treatment at discharge, and a significant HbA1c reduction was seen three months after discharge in the postimplementation phase (P=0.04). The professionals assigned the protocol a score of 4.5 on a 1 to 5 scale. CONCLUSIONS: Incorporation of a nurse consultant expert in diabetes as key component of a hyperglycemia management program ensures that a majority of patients admitted to hospital for hyperglycemia receive treatment with a basal-bolus regimen and improves blood glucose control during hospital stay and after discharge.

Comparison of Routine and Computer-Guided Glucose Management for Glycemic Control in Critically Ill Patients.

BACKGROUND: Glycemic control is crucial for reducing morbidity and mortality in critically ill patients. A standardized approach to glycemic control using a computer-guided protocol may help maintain blood glucose level within a target range and prevent human-induced medical errors. OBJECTIVE: To determine the effectiveness of a computer-guided glucose management protocol for glycemic control in intensive care patients. METHODS: This controlled, open-label implementation study involved 66 intensive care patients: 33 in the intervention group and 33 in the control group. The blood glucose level target range was established as 120 to 180 mg/dL. The control group received the clinic's routine glycemic monitoring approach, and the intervention group received monitoring using newly developed glycemic control software. At the end of the study, nurse perceptions and satisfaction were determined using a questionnaire. RESULTS: The rates of hyperglycemia and hypoglycemia were lower and the blood glucose level was more successfully maintained in the target range in the intervention group than in the control group (P < .001). The time to achieve the target range was shorter and less insulin was used in the intervention group than in the control group (P < .05). Nurses reported higher levels of satisfaction with the computerized protocol, which they found to be more effective and reliable than routine clinical practice. CONCLUSIONS: The computerized protocol was more effective than routine clinical practice in achieving glycemic control. It was also associated with higher nurse satisfaction levels.

Perioperative Hyperglycemia: A Literature Review.

The purpose of this literature review is to examine current evidence and determine the effects of stress hyperglycemia on patient outcomes during the perioperative period. This review summarizes the pathophysiology of stress hyperglycemia, the population it affects, and strategies for optimal treatment to reduce the potential for postoperative complications. A literature search produced 16 of the most current studies on the effect of stress hyperglycemia in both the diabetic and nondiabetic populations. The evidence presented indicates the need to maintain tight glucose control in the perioperative patient. Although there are varying approaches to managing stress hyperglycemia, there is compelling agreement that stress hyperglycemia should be treated in all surgical patients.

Conocimiento y actitud frente a la enfermedad de personas con diabetes mellitus atendidas en Atención Primaria / Conhecimento e atitude frente a doença de pessoas com diabétes mellitus assistidas na Atenção Primária à Saúde / Knowledge and attitude towards the disease of people with diabetes mellitus assisted in Primary Health Care

Objetivo: Determinar la prevalencia de los conocimientos y la actitud de las personas con diabetes mellitus tipo 2 en relación con la enfermedad y los factores asociados. Métodos: Investigación en los domicilios con 398 personas con diabetes mellitus tipo 2 inscritas en Atención Primaria. Se aplicaron tres cuestionarios: uno para el levantamiento de datos sociodemográficos y clínicos; el conocimiento de la diabetes Cuestionario (DKN-A) y la actitud de la diabetes Cuestionario (ATT-19). Para el análisis de datos, se utilizaron las pruebas bivariados y de regresión logística múltiple. Resultados: Más de la mitad de los sujetos (55,8%) tenía poco conocimiento sobre la enfermedad y la mayoría (92,2%), dificultad para resolverlos. Se verificó asociación entre el conocimiento acerca de la enfermedad con ocho o más años de estudio, cintura normal de la cadera, verificación de la glucosa en sangre regularmente, y relación inversa con el tiempo de diagnóstico <10 años. La actitud positiva hacia la enfermedad se asoció con edad entre 50 y 60 años y, a la inversa, con episodios de hiperglucemia. Conclusión: La baja prevalencia de conocimientos y actitudes positivas a la enfermedad. En cuanto a los factores asociados, cabe señalar que la mayoría de los destacados en este estudio no son modificables, lo que refuerza la importancia de que las actividades de promoción de la salud se centraron en gran medida en los grupos con estos factores

Objetivo: Verificar a prevalência do conhecimento e atitude de pessoas com diabetes mellitus tipo 2 em relação à doença e os fatores associados. Métodos: Inquérito domiciliar realizado com 398 pessoas com diabetes mellitus tipo 2 cadastradas na Atenção Primária. Foram aplicados três questionários: um para levantamento de dados sóciodemográficos e clínicos; o Diabetes Knowledge Questionnaire (DKN-A) e o Diabetes Attitude Questionnaire (ATT-19). Para análise dos dados, utilizou-se testes bivariados e regressão logística múltipla. Resultados: Mais da metade dos indivíduos (55,8%) apresentou conhecimento insatisfatório sobre a doença e a maioria (92,2%), dificuldade para o seu enfrentamento. Verificou-se associação entre conhecimento sobre a doença com oito ou mais anos de estudo, relação cintura quadril normal, verificação da glicemia capilar regular e, relação inversa com o tempo de diagnóstico <10 anos. A atitude positiva frente a doença apresentou associação com idade entre 50 a 60 anos e, de modo inverso, com episódios de hiperglicemia. Conclusão: A prevalência de conhecimento e atitudes positivas frente à doença foi considerada reduzida. Quanto aos fatores associados, salienta-se que a maioria daqueles evidenciados nesse estudo não são passíveis de modificação, reforçando a importância das atividades de promoção da saúde focadas sobremaneira nos grupos que apresentam estes fatores

Objective: To verify the prevalence of knowledge and attitude of people with diabetes mellitus type 2 in relation to the disease and associated factors. Methods: A household survey of 398 people with diabetes mellitus type 2 enrolled in Primary Care. Three questionnaires were applied: one for sociodemographic and clinical data collection; the Diabetes Knowledge Questionnaire (DKN-A) and the Diabetes Attitude Questionnaire (ATT-19). For data analysis, bivariate tests and multiple logistic regression were used. Results: More than half of the individuals (55.8%) presented unsatisfactory knowledge about the disease and the majority (92.2%) had difficulty in coping with it. There was an association between knowledge about the disease with eight or more years of study, normal waist hip ratio, regular capillary blood glucose check, and inverse relationship with time of diagnosis <10 years. The positive attitude towards the disease presented an association with age between 50 and 60 years and, conversely, with episodes of hyperglycemia. Conclusion: The prevalence of knowledge and positive attitudes towards the disease was considered low. As for the associated factors, most of those evidenced in this study are not subject to modification, reinforcing the importance of health promotion activities that are especially focused on the groups that present these factors

Hyperglycemia Syndromes.

Diabetes mellitus and its complications are among the leading causes of organ failure around the world. It is imperative that timely, patient-centered care is provided to avoid microvascular and macrovascular damage. People with well-controlled diabetes can live long and healthy lives through interprofessional management, emphasizing optimal, individualized care.

Strict versus liberal insulin therapy in the cardiac surgery patient: An evidence-based practice development, implementation and evaluation project.

BACKGROUND: Hyperglycemia post-cardiac surgery is associated with poor clinical outcomes. Recent studies suggest maintaining liberal glycemic control (<180mg/dL) using a continuous insulin infusion (CII) versus strict control achieves optimal outcomes and prevents hypoglycemia. PURPOSE: To develop, implement and evaluate a nurse managed liberal CII protocol. METHODS: Retrospective review of 144 strict CII patient records and 147 liberal CII patient records. RESULTS: Mean blood glucose was 159.8mg/dL (liberal CII) compared to 143.3mg/dL (strict CII) (p≤0.001). No surgical site infections occurred in either group. Mean ICU length of stay was 4.5days (liberal) versus 4.4days (strict) (p=0.74). Two 30-day mortalities occurred for the liberal cohort compared to no deaths in the strict group (p=0.49). Hypoglycemia incidence within 24h after surgery was 0.1% (liberal) compared to 0.3% (strict) compared to (p=0.16). CONCLUSION: Use of a nurse managed liberal CII resulted in similar outcomes with fewer incidents of hypoglycemia.

Indicators for best practices in glycemic control in the intensive care unit / Indicativos para mejores prácticas en el control glicémico en una unidad de terapia intensiva / Indicativos para melhores práticas no controle glicêmico em unidade de terapia intensiva

Abstract Objective: To understand the perception of the nursing team' regarding the management of the intensive glycemic control protocol in order to obtain better practices in glycemic control in the Intensive Care Unit of a University Hospital. Method: A qualitative, convergent care study carried out in an Intensive Care Unit of a university hospital. The data were collected through interviews and workshops and analyzed through thematic analysis. Thirty nursing professionals participated in the study. Results: The importance of the glycemic control protocol which standardizes and guides care was reported by the participants, however they indicated that the used protocol is confusing, difficult to understand and does not include some important guidelines. Restructuring was recommended by adding aspects such as: the desired glycemic value, spaces between glycaemia recording, diet and others; as well as training for its application. Conclusion: The participants recognized the weaknesses of the protocol, and reaffirmed the potentialities of this instrument and defended permanent education as a fundamental factor for the best practices in intensive care.

Resumen Objetivo: Conocer la percepción del equipo de enfermería sobre el manejo del protocolo de control glicémico intensivo, con el objetivo de obtener mejores prácticas en el control glicémico en la Unidad de Terapia Intensiva de un Hospital Universitario. Método: Estudio cualitativo y convergente asistencial realizado en una Unidad de Terapia Intensiva de un hospital universitario. Los datos fueron obtenidos através de entrevistas y talleres y analizados através del análisis temático. Participaron del estudio 30 profesionales de enfermería. Resultados: Relatan la importancia del protocolo de control glicémico que estandariza y guía la asistencia. Sin embargo, refieren que el protocolo utilizado es confuso, difícil de entender y no contempla algunas orientaciones importantes. Recomiendan su reestructuración agregando aspectos como: valor de glicemía pretendido, espaciamiento entre glicemías, dieta y otros, y la capacitación para su ejecución. Conclusión: Reconocen las fragilidades del protocolo utilizado, reafirman las potencialidades de este instrumento y defienden la educación permanente como factor fundamental para mejores prácticas en terapia intensiva.

Resumo Objetivo: Conhecer a percepção da equipe de enfermagem quanto ao manejo do protocolo de controle glicêmico intensivo, com vistas a obter melhores práticas no controle glicêmico na Unidade de Terapia Intensiva de um Hospital Universitário. Método: Estudo qualitativo, convergente assistencial, realizado em Unidade de Terapia Intensiva de um hospital universitário. Os dados foram coletados através de entrevistas e oficinas e analisados por meio da análise temática. Participaram do estudo 30 profissionais de enfermagem. Resultados: Relatam a importância do protocolo de controle glicêmico, que padroniza e guia a assistência, entretanto referem que o protocolo utilizado é confuso, difícil de entender não contemplando algumas orientações importantes. Recomendam sua reestruturação acrescentando aspectos como: valor de glicemia pretendido, espaçamento entre glicemias, dieta e outros; bem como capacitação para sua execução. Conclusão: Reconhecem as fragilidades do protocolo utilizado, reafirmam as potencialidades desse instrumento e defendem a educação permanente como fator fundamental para as melhores práticas em terapia intensiva.

Cuidados al paciente con estado hiperosmolar hiperglucémico en una Unidad de Medicina Intensiva / Care for patients in hyperosmolar hyperglycaemic state at the Intensive Care Unit

La diabetes mellitus constituye un problema importante de salud, ya que en los últimos 20 años se ha triplicado el número de personas que viven con esta enfermedad en todo el mundo. Una de las principales complicaciones agudas de la diabetes es el estado hiperosmolar hiperglucémico (EHH), causado por la deficiencia de insulina, acompañado de disminución de la volemia con o sin anormalidad del equilibrio ácido-base, y caracterizado por hiperosmolaridad plasmática consecuencia de la deshidratación grave. En esta ocasión se presenta un caso clínico de un paciente con diagnóstico de EHH, atendido en una Unidad de Medicina Intensiva, utilizando la metodología del proceso de Enfermería con la taxonomía NANDA-NIC-NOC, según el modelo conceptual de Virginia Henderson. Las intervenciones de Enfermería, junto a las actuaciones del equipo multidisciplinar, permitieron la remisión del diagnóstico a los siete días del ingreso, obteniendo como resultado un menor compromiso del estado de salud del paciente (AU)

Diabetes Mellitus represents a major health problem, because during the last 20 years the number of persons who live with this disease has tripled around the world. One of the main acute complications of diabetes is the Hyperosmolar Hyperglycaemic State (HHS), caused by insulin deficiency, accompanied by a reduction in blood volume with or without an abnormal acid-base balance, and characterized by plasma hyperosmolarity caused by severe dehydration. We present here the clinical case of a patient diagnosed with HHS, managed at an Intensive Care Unit, using the methodology of the nursing procedure with the NANDA-NIC-NOC taxonomy, according to Virginia Henderson's Conceptual Model. Nursing interventions, together with the actions by the multidisciplinary team, allowed the remission of diagnosis at seven days of admission, obtaining as a result a lower involvement in the patient's health condition (AU)

International Uptake of a Proven Intervention to Reduce Death and Dependency in Acute Stroke: A Cross-Sectional Survey Following the QASC Trial.

BACKGROUND: Uptake of proven interventions requires dedicated resources that may only result in local implementation, thus precluding international practice change. We explored international uptake through online dissemination of the fever, sugar, and swallow (FeSS) protocols from the Quality in Acute Stroke Care (QASC) trial, which showed decreased death and dependency by 15.7% 90-day poststroke. AIMS: To identify: (a) the clinical discipline of healthcare professionals who downloaded the QASC resources; (b) the purpose for downloading; (c) successful implementation of any or all the FeSS protocols; (d) barriers to implementation; and (e) associations with self-reported successful implementation. METHODS: A cross-sectional, online survey of those who downloaded the QASC resources between October 2011 and August 2013. Associations between implementation and participant characteristics were determined. RESULTS: One-hundred and fifty-nine people from 21 countries participated. Nurses were the largest group to download the resources (n = 54, 38%), with the primary purpose to inform clinical practice (n = 97, 64%). Less than half (n = 77, 48%) downloaded, and less than a quarter (n = 38, 24%) attempted to implement all three protocols. Of those personally involved in implementation (n = 50) half reported doing so successfully for one or more protocols (n = 27, 54%) with 10 (20%) reporting successful implementation of all three protocols. Only about half (n = 13, 48%) used the proven implementation strategy with about one-third (n = 10, 29%) confirming successful uptake via audit. Implementation barriers were potential increase in nursing workload (n = 28, 56%) and lack of medical staff engagement (n = 27, 53%). Higher autonomy was associated with greater likelihood of implementation of all three protocols (p = .038). LINKING EVIDENCE TO ACTION: The QASC intervention required use of all three protocols. However, less than half downloaded them all and implementation was not guided by the proven implementation strategy. While encouraging that these resources were being used to drive practice change, piecemeal implementation of a proven intervention is unlikely to improve patient outcomes.

Nurse-Directed Blood Glucose Management in a Medical Intensive Care Unit.

BACKGROUND: Insulin-delivery algorithms for achieving glycemic control in the intensive care unit require frequent checks of blood glucose level and thus increase nursing workload. Hypoglycemia is a serious complication associated with intensive insulin therapy. OBJECTIVES: To evaluate a nurse-directed protocol for blood glucose management that allows individualized insulin delivery within a predefined blood glucose corridor, intended to avoid hypoglycemia while maintaining adequate control of blood glucose level without increasing nursing workload. METHODS: A nurse-directed protocol for blood glucose management was developed by an interprofessional team, and the protocol's performance was investigated in 175 patients compared with 384 historical controls. RESULTS: With the nurse-directed protocol, hypoglycemia incidents declined significantly (31% vs 12%, P < .001), and minimum blood glucose levels increased significantly (80 mg/dL vs 93 mg/dL, P < .001). Mean and maximum blood glucose levels, the proportion of glucose readings within the target range (31% vs 26%, P = .06), and the number of blood glucose checks (59 vs 58, P = .85) remained unchanged with use of the protocol. CONCLUSION: Implementation of the nurse-directed protocol for blood glucose management did not increase nursing workload but reduced hypoglycemia incidents significantly while maintaining adequate glycemic control.

Nursing Protocol for Stroke Increases Survival, Reduces Disability.

Fever, hyperglycemia, and swallowing problems were treated in the first 72 hours following stroke.

Hyperglycemia and Cancer: An Algorithm to Guide Oncology Nurses
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BACKGROUND: A dual diagnosis of cancer and hyperglycemia has demonstrated untoward effects on patients' cancer treatment, prognosis, and survival. 
. OBJECTIVES: The purpose of this evidence-based project is to improve knowledge and awareness of the consequences of hyperglycemia in patients with cancer, increasing nurses' capability to effectively intervene. In addition, a clinical algorithm based on current evidence was developed and is presented.
. METHODS: An educational program was developed and pilot tested. The program addressed the etiology of hyperglycemia and its effects on patients with cancer. Knowledge of hyperglycemia in patients with cancer was assessed with a pre- and post-test.
. FINDINGS: All participants found the educational program effective and deemed the clinical algorithm useful. Results improved significantly after participation in the educational intervention.

Glycaemic variability in patients with severe sepsis or septic shock admitted to an Intensive Care Unit.

BACKGROUND: Sepsis is associated with morbidity and mortality, which implies high costs to the global health system. Metabolic alterations that increase glycaemia and glycaemic variability occur during sepsis. OBJECTIVE: To verify mean body glucose levels and glycaemic variability in Intensive Care Unit (ICU) patients with severe sepsis or septic shock. METHOD: Retrospective and exploratory study that involved collection of patients' sociodemographic and clinical data and calculation of severity scores. Glycaemia measurements helped to determine glycaemic variability through standard deviation and mean amplitude of glycaemic excursions. RESULTS: Analysis of 116 medical charts and 6730 glycaemia measurements revealed that the majority of patients were male and aged over 60 years. Surgical treatment was the main reason for ICU admission. High blood pressure and diabetes mellitus were the most usual comorbidities. Patients that died during the ICU stay presented the highest SOFA scores and mean glycaemia; they also experienced more hypoglycaemia events. Patients with diabetes had higher mean glycaemia, evaluated through standard deviation and mean amplitude of glycaemia excursions. CONCLUSION: Organic impairment at ICU admission may underlie glycaemic variability and lead to a less favourable outcome. High glycaemic variability in patients with diabetes indicates that monitoring of these individuals is crucial to ensure better outcomes.

Assessment and management of the septic patient: part 2.

Sepsis has gained increasing publicity in recent years, and there is now a strong focus of clinical education and training following the Surviving Sepsis Campaign. The assessment and management of a septic patients is far from simple and requires a systematic approach in both identifying and managing the condition. This second part explores sepsis care bundles and the research that underpins each of the interventions. These discussions will enable nurses to understand why each component of the sepsis care bundle is important and thus enable them to rapidly prioritise care, as early effective interventions have been shown to optimise patient outcomes.