In a world full of processed sugars and fast food dollar menus, it is no wonder “more than 1 in 10 health care dollars in the U.S. are spent directly on diabetes and its complications,” (Thomas, 2013, p.62).

According to the American Diabetes Association, the diagnosis of diabetes is made with a fasting blood glucose of 126mg/dl or higher. Known risk factors for diabetes include: being overweight, inactivity, race, genetics etc. While diet, exercise, frequent blood glucose checks and adherence to medication regiment can control a diabetic’s insulin imbalance, alcohol consumption, nicotine usage, and medication noncompliance sabotages he management of diabetes (Vermire, et al, 2007).

Case Study Seven Patient Focused Question

Amy, a 36-year-old Caucasian female, has been admitted to Roll Tide Hospital with a blood sugar of 300. Amy is 50 pounds overweight, smokes, drinks 10-12 beers a week and does not adhere to her medication regime of insulin. She is place on an insulin drip. The insulin drip protocol at the hospital is to maintain serum blood sugar between 70 and 110 mg/dl. A few month ago, a pilot research project indicated that a mean serum blood sugar for patient discharged from cardiac care units was 148. The nurses providing care to Amy ponder if the current protocol ranges are appropriate.

Introduction

After first determining that the category for needed information concerns treatment decision were made regarding the best research source to find reliable evidence. Evidence relevant to both the case and focused question was sought. Team made decisions to target the highest level of evidence available in regards the focused clinical question. PPAARE {problem, patient, action, alternative, result, evidence) was used to guide the search (see table 1). The PubMed database was primarily used in the search to answer the case’s focused question.

Target resources/ Evidence Search Conclusions Based on the evidence the use of an insulin drip in a critically

ill patient does not demonstrate reduced mortality. The high rates of excessive hypoglycemia suggest the lack of benefit of an insulin drip protocol. The targeting of very strict ranges of blood glucose level further adds to the complexity of implementing an insulin drip protocol.  Hyperglycemia has many detrimental complications. However, there needs to be more researches and trials on how to decrease hyperglycemia without the increase mortality. Insulin drips protocols should be individualized and not be a generalized approach. Evidence base practice has shown that an insulin drip might not be as beneficial to Amy although she is very sick. The institution should strive to individualized insulin drip protocol based on the case that the patient presents.

References Griesdale, D. M., Heyland, D. K., Cook, D. J.,

Malhotra, A., Dhaliwal, R., Henderson, W. R., Chittock, D. R., Finfer, S. & Talmor, D. (2009). Intensive insulin therapy and mortality among ill patients: A meta-analysis including NICE – sugar study data. Canadian medical Association Journal. Advance online publication. doi: 10. 1503/cmaj.090206

Kansagara, D., Fu, R., Freeman, M., Wolf, F., Helfand, M. (2011).Intensive insulin therapy in hospitalized patients: A systematic review. Annals of Internal Medicine, 154, 268-282 Retrieved from http://annals.org/

Thomas, M. B. (2013). Healthcare industry takes action to combat diabetes costs. Case Management Advisor, 24, 61-63.

Vermeire, E.J., Wen, J., Van Royen, P., Biot, Y., Hearnshaw, H., & Lindenmyer, A. (2005). Interventions for improving adherence to treatment recommendation in the people with

Diabetes mellitus. Cochrane Datebase of Systematic Review, (2), 1-45. doi: 10.1002/14651858.

The purpose and goal of the query to determine if the current blood glucose protocol is appropriate in the treatment of the patient presented in case study seven. Amy is non-adherent with her insulin regime. Her lifestyle of drinking, smoking and being 50 pounds overweight drastically increased her risk for uncontrolled hyperglycemia.

Is an insulin drip protocol of 70-110mg/dl appropriate for 36-year-old Caucasian female who present with a blood glucose of 300mg/dl and is none adherent with current insulin regimen?

1 in 10 healthcare dollars are spent directly on diabetes and its complications

Griedale and the research team conducted a quantitative research study of 26 random control trials of intensive insulin therapy on mortality and hypoglycemia in the ICU setting. Intensive insulin therapy that target a blood glucose between 80mg/dl to 110 mg/dl reported evidence of severe hypoglycemia and increased mortality. Intensive insulin therapy that targets a blood glucose of 114 mg/dl to 150 mg/dl are safe blood glucose target levels. The quantitative study finding did not support widespread adoption of intensive insulin therapy in a critically ill patient due to increased risk of hypoglycemia.

Course of Action Due to the lack of evidence supporting the

safety and effectiveness of an institution’s standardized insulin drip protocol in substantially ill patients, it can be concluded that Roll Tide Hospital should strive to individualized insulin drip protocol on a case by case basis.

The healthcare professionals on Amy’s case should present this evidence to the hospital’s committee and encourage the protocol be reconsidered.

Advocating for this revision may help to ensure the safety of Amy along with future patients who are critically ill from high blood glucoses..

Relevant Evidence

Auburn University at Montgomery

Evidence Base Practice: Case Study Seven

PPAARE COMPONE

NT

CASE EXAMPLE

Problem Diabetic with a blood glucose of 300mg/dl

Patient 36-year-old Caucasian female that smokes, drinks and non-adherent with insulin regimen

Action Researches and the appropriateness of the current insulin drip protocol range of 70-110mg/dl

Alternative

None

Patient Results

Identifies the appropriateness of the insulin drip protocol range

Level of Evidence

Meta-analyses and systematic review evidence-base-review Randomized control trial

Demetrius Steele, Denelia A. Clahar and Kathryn H. Kicklighter