Glycemic Control Goal

Definition
The literature suggests appropriate glycemic control in the ICU reduces morbidity and overall mortality in the critically ill. [1,2,3] The NICE-SUGAR study investigators chose to evaluate whether there was a difference in mortality between subjects randomly assigned to either intensive glucose control, with a target blood glucose range of 81 to 108 mg per deciliter (4.5 to 6.0 mmol per liter), or conventional glucose control, with a target of 180 mg or less per deciliter (10.0 mmol or less per liter). The results showed that targeting glucose values less than 180 mg/dl resulted in lower mortality than the tighter range of 81 to 108 mg/dl. The odds of dying with intensive control were 1.14 times greater than with conventional control (P=0.02). [3]   
 
Measurement Strategy
We suggest a three-part measurement system to assess the adequacy of glucose control over time, assessing the range of glucose values in critically ill patients on a monthly basis. Optimization of the percentage of patients within glucose values less than 180 mg per deciliter (4.5 to 6.0 mmol per liter) is preferred. There is also value in considering the lower limit of normal at your institution, which is typically 60 to 70 mg per deciliter as a marker of relative hypoglycemia. 
 
A separate measure has been configured to assess the risk of severe hypoglycemia less than or equal to 40 mg per deciliter (2.2 mmol per liter). (See Incidence of Severe Hypoglycemic Episodes.)
 
Percent of blood sugars in the 60 to 180 mg/dL range
  • Type of measure: Outcome
  • Aim: Increase
  • Measure calculation: Numerator/denominator * 100
Numerator: Number of ICU glucose values within 60 to 180 mg/dL in the current month
Denominator: Total number of glucose tests done in the ICU in the current month
  • Goal: 80 percent or more blood sugars are in the 60 to 180 mg/dL range
 
Percent of blood sugars in the 0 to 59 mg/dL range
  • Type of measure: Balancing
  • Aim: Decrease
  • Measure calculation: Numerator/denominator * 100
Numerator: Number of ICU glucose values within 0 to 59 mg/dL in the current month
Denominator: Total number of glucose tests done in the ICU in the current month
  • Goal: Less than 2 percent of blood sugars are in the 0 to 59 mg/dL range
 
Percent of blood sugars greater than 181 mg/dL
  • Type of measure: Balancing
  • Aim: Decrease
  • Measure calculation: Numerator/denominator * 100
Numerator: Number of ICU glucose values 181 mg/dL or above in the current month
Denominator: Total number of glucose tests done in the ICU in the current month
  • Goal: Less than 20 percent of blood sugars are in the greater than 181 mg/dL range
 
Goal 
See goals above in Measurement Strategy.
 
Data Collection Plan
Frequency of Collection:
Ideally, data collection would occur daily with calculation of results monthly for the most accurate assessment of performance. However, in the absence of obtaining batched data from your information technology department or central laboratory on a regular basis, this is an ambitious collection effort. For manual collection of data, the frequency of sample collection may be twice weekly or even once weekly. Trends become more difficult to interpret reliably as the interval between data collection periods increases, however.
 
Point-of-Care Testing:
Special considerations come into play with regard to collecting data for glucose measurement. If you intend to rely on batched data from the central laboratory this may or may not include point-of-care finger stick glucose values. Since most glucose values collected from patients on an insulin drip tend to be point-of-care collections, an accurate tally should include these values.
 
Clinical Evidence:
  1. Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. New England Journal of Medicine. 2001 Nov 8;345(19):1359-1367.
  2. Van den Berghe G, Wilmer A, Hermans G, et al. Intensive insulin therapy in the medical ICU. New England Journal of Medicine. 2006 Feb 2;354(5):449-461.
  3. NICE-SUGAR Study Investigators, Finfer S, Chittock DR, Su SY, et al. Intensive versus conventional glucose control in critically ill patients. New England Journal Medicine. 2009 Mar 26;360(13):1283-1297.
 
 

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