title: Adoption and implementation of the original strict glycemic control guideline is feasible and safe in adult critically ill patients.
abstract: BACKGROUND
  Three trials of tight glucose control (TGC) found clinical benefit of normalization of blood glucose levels in the intensive care unit (ICU). Implementation of TGC was imperfect in subsequent trials, since attained blood glucose levels (BGLs) never reached the targets as in the original trials of TGC. We investigated whether implementation of the TGC guideline as used in the original trials of TGC is feasible and safe.
  
  
  METHODS
  In this study 3 ICUs adopted and implemented the TGC guideline as used in the original trials of TGC using a multifaceted practice change strategy; 3 ICUs that did not change their blood glucose control guideline served as controls. TGC was practiced by physicians and nurses during the first 12-month (period-2), thereafter exclusively by nurses (period-3). Blood glucose metrics 12-month before (period-1) and 24-month after implementation of the guideline were compared.
  
  
  RESULTS
  The analysis included 1321 in period-1, 1169 and 1006 patients in period-2, and -3, respectively, in the intervention ICUs, and 3110 patients in the control ICUs. After implementation of the new TGC guideline, patients in intervention ICUs had lower median BGLs (105 [IQR: 85-130] mg/dL vs. 119 [99-150] mg/dL in period-1, P<0.001; and vs. 113 [95-141] mg/dL in control ICUs, P<0.001). The incidence of severe hypoglycemia initially increased, but again decreased when exclusively nurses practiced TGC, and was not associated with increased mortality or morbidity.
  
  
  CONCLUSIONS
  Implementation of the original TGC guideline is feasible and safe. Our study suggests a learning effect over time.
authors.affiliation: Department of Intensive Care, Academic Medical Center, University of Amsterdam, The Netherlands. m.j.schultz@amc.uva.nl
authors.forename: M J
authors.initials: MJ
authors.lastname: Schultz
authors.forename: R E
authors.initials: RE
authors.lastname: Harmsen
authors.forename: J C
authors.initials: JC
authors.lastname: Korevaar
authors.forename: A
authors.initials: A
authors.lastname: Abu-Hanna
authors.forename: F
authors.initials: F
authors.lastname: Van Braam Houckgeest
authors.forename: J P
authors.initials: JP
authors.lastname: Van Der Sluijs
authors.forename: P E
authors.initials: PE
authors.lastname: Spronk
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001786:Blood Glucose / Q000032:analysis*; D002940:Circadian Rhythm; D003422:Critical Care / Q000379:methods / Q000592:standards*; D016638:Critical Illness / Q000401:mortality / Q000451:nursing; D005260:Female; D019983:Guideline Adherence; D017052:Hospital Mortality; D006764:Hospitals, Community; D006801:Humans; D006943:Hyperglycemia / Q000188:drug therapy / Q000453:epidemiology / Q000517:prevention & control*; D007003:Hypoglycemia / Q000453:epidemiology / Q000517:prevention & control; D007328:Insulin / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D009426:Netherlands / Q000453:epidemiology; D017410:Practice Guidelines as Topic
chemical_list: D001786:Blood Glucose; D007328:Insulin