Nurse- vs nomogram-directed glucose control in a cardiovascular intensive care unit

Clarence Chant, Mary Mustard, Kevin E Thorpe, Jan O Friedrich
American Journal of Critical Care: An Official Publication, American Association of Critical-Care Nurses 2012, 21 (4): 270-8

BACKGROUND: Paper-based nomograms are reasonably effective for achieving glycemic control but have low adherence and are less adaptive than nurses' judgment.

OBJECTIVE: To compare efficacy (glucose control) and safety (hypoglycemia) achieved by use of a paper nomogram versus nurses' judgment.

METHODS: Prospective, randomized, open-label, crossover trial in an intensive care unit in postoperative patients with glucose concentrations greater than 8 mmol/L. Consenting nurses with at least 1 year of experience were randomized to use either their judgment or a validated paper-based nomogram for glucose control. After completion of 2 study shifts, the nurses used the alternative method for the next 2 study shifts. Glucose target level and safety and efficacy boundaries were the same for both methods. The primary end point was area under glucose time curve per hour.

RESULTS: Thirty-four nurses contributed 95 shifts of data (44 nomogram-directed, 51 nurse-directed). Adherence to the nomogram was higher in the nomogram group than hypothetical adherence in the nurse-directed group for correct adjustments in insulin infusion (70% vs 37%; P < .001) and glucose checks (58% vs 43%; P = .008). The primary end point did not differ between the 2 groups (mean, 9.0 mmol/L; SD, 3.5 vs mean, 8.3 mmol/L; SD, 2.1; P = .08). Glucose variability, amount of time patients were hypoglycemic or hyperglycemic, and number of glucose checks performed were similar in the 2 groups.

CONCLUSIONS: In an intensive care unit where nurses generally accepted the need for tight glucose control, nurse-directed control was as effective and as safe as nomogram-based control.

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