Implementing glucose control in intensive care: a multicenter trial using statistical process control.
BACKGROUND
Glucose control (GC) with insulin decreases morbidity and mortality of critically ill patients. In this study we investigated GC performance over time during implementation of GC strategies within three intensive care units (ICUs) and in routine clinical practice.


METHODS
All adult critically ill patients who stayed for >24 h between 1999 and 2007 were included. Effects of implementing local GC guidelines and guideline revisions on effectiveness/efficiency-related indicators, safety-related indicators, and protocol-related indicators were measured.


RESULTS
Data of 17,111 patient admissions were evaluated, with 714,141 available blood glucose levels (BGL) measurements. Mean BGL, time to reach target, hyperglycemia index, sampling frequency, percentage of hyperglycemia events, and in-range measurements statistically changed after introducing GC in all ICUs. The introduction of simple rules on GC had the largest effect. Subsequent changes in the protocol had a smaller effect than the introduction of the protocol itself. As soon as the protocol was introduced, in all ICUs the percentage of hypoglycemia events increased. Various revisions were implemented to reduce hypoglycemia events, but levels never returned to those from pre-implementation. More intensive implementation strategies including the use of a decision support system resulted in better control of the process.


CONCLUSIONS
There are various strategies to achieve GC in routine clinical practice but with variable success. All of them were associated with an increase in hypoglycemia events, but GC was never stopped. Instead, these events have been accepted and managed. Statistical process control is a useful tool for monitoring phenomena over time and captures within-institution changes.
Eslami
Saeid
S
Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Meibergdreef 15, 1105 AZ, Amsterdam, The Netherlands. s.eslami@amc.uva.nl
Abu-Hanna
Ameen
A
de Keizer
Nicolette F
NF
Bosman
Rob J
RJ
Spronk
Peter E
PE
de Jonge
Evert
E
Schultz
Marcus J
MJ
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002985:Clinical Protocols; D003422:Critical Care / Q000379:methods*; D016638:Critical Illness / Q000453:epidemiology / Q000628:therapy*; D020000:Decision Support Systems, Clinical; D005260:Female; D006284:Health Plan Implementation; D006801:Humans; D006943:Hyperglycemia / Q000188:drug therapy* / Q000453:epidemiology; D007003:Hypoglycemia / Q000188:drug therapy* / Q000453:epidemiology; D007004:Hypoglycemic Agents / Q000627:therapeutic use*; D007328:Insulin / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009426:Netherlands / Q000453:epidemiology; D012189:Retrospective Studies; D017751:Safety Management / Q000458:organization & administration; D016896:Treatment Outcome; D055815:Young Adult
D007004:Hypoglycemic Agents; D007328:Insulin