| BackgroundCritically ill patients are highly susceptible to stress hyperglycemia(SHG),regardless of whether they have a history of diabetes.Elevated blood glucose levels are strongly associated with adverse clinical outcomes in critically ill patients.However,there is no evidence-based practice protocol to guide ICU nurses in the practice of glycemic management.The translation and dissemination of evidence-based practice protocols for glycemic management in critically ill adults and the effectiveness of their application also need to be urgently explored.Objectives1.To describe the current practice of glycemic management in critically ill adult patients in China,the knowledge,attitudes and behaviors of ICU health care professionals and their experiences.2.To synthesize the best evidence on glycemic management in critically ill adults and develop an evidence-based practice protocol for glycemic management in critically ill adult patients under a local scenario.3.To explore the process of the implementation of evidence into practice and ultimately improve patient glycemic management and clinical outcomes while promoting evidence-informed decision-making(EIDM)among ICU health care professionals through evidence utilization.MethodThis study was based on the Rosswurm&Larrabee model of evidence-based practice changes.In the clinical context study phase,a mixed research method-parallel triangulation strategy was used to describe the current practice of glycemic management in critically ill adult patients in China,describe the knowledge,attitudes and behaviors of ICU health care professionals and their experiences and to clarify the framework and dimensions of evidence synthesis.In the process of protocol development,a literature search of clinical decision support systems(CDSS),guidelines and expert consensuses and a systematic review(SR)related to glycemic management in critically ill adult patients was performed;the evidence quality was rated based on the Joanna Briggs Institute(JBI)levels of evidence and grades of recommendation(2014).After several rounds of Delphi expert consultations,the“Evidence-based Practice Protocol for glycemic management in critically ill adult patients”was formed.In the process of protocol dissemination and application,the content of the protocol was transformed into a standard operation procedure,and noncontemporaneous,before-and-after controlled research was used to evaluate the effectiveness of protocol application in terms of the process,outcome,and system level at the pilot site.Results1.Results of field research:A total of 60 patients and 12 ICU nurses were observed in four field sites.All fields had insulin infusion protocols(IIPs)for glycemic management,with a mean protocol duration of 9±2.92years,and the IIP content in all fields was not comprehensive and needed to be updated.Patients had poor glycemic control with a high mean hypoglycemia incidence(14.1%),an excessively long time required to reach the target glucose range(7.76-18.69 h),a longer mean hyperglycemia duration(7.04-18.9 h),and a shorter duration of the target glucose range(5.59-8.53 h);with no statistically significant differences among the different field sites.The main tasks of glucose control for ICU nurses included insulin infusion and adjustment,blood glucose monitoring,nutritional management,and hypoglycemia treatment.There were still problems such as a limited scope of practice,non-standardized operation,overreliance on one’s own experience,a lack of professional knowledge and"protocol violations".2.The current situation of the"knowledge-attitudes-behaviors"(KAP)of ICU health care professionals:A questionnaire on the knowledge,attitudes,and behaviors of blood glucose management among ICU health care workers was developed,with a Cronbach’sαvalue of 0.926 for the total questionnaire and Cronbach’sαvalues of 0.885,0.926,and 0.730 for the knowledge,attitude,and behavior dimensions,respectively.A total of381 ICU physicians and nurses were included in this study,with mean scores of 82.35%,87.69%,and 76%for the three dimensions of knowledge,attitudes,and behaviors,respectively.The main factors influencing the KAP of glycemic management among ICU health care workers were the level of knowledge about glycemic management(β=0.373),the level of awareness of the importance of glycemic management(β=0.241),and training(β=0.133).3.ICU health care professionals’experience in blood glucose management:A total of 15 ICU physicians and nurses from 10 tertiary hospitals in China were interviewed,and elements of glycemic management in critically ill adult patients were extracted from the interview data,namely,glycemic assessment,insulin infusion,glycemic monitoring,nutrition and medication,hypoglycemic management,glycemic management methods,quality control and feedback,and leadership,which led to the development of a model for glycemic management in critically ill adult patients.4.Evidence synthesis results:A systematic literature search and screening was conducted for eight clinical issues related to glycemic management,including management and coordination,the target range of glycemic control,insulin infusion and adjustment,glucose monitoring,medication and nutrition,the prevention and management of hypoglycemia,special cases of glycemic management,education and training.The literature sources of evidence that were eventually incorporated into the“Evidence-based practice protocol for glycemic management in critically ill adult patients”(draft)included 3 CDSS,12 guidelines,7 expert consensuses,and 27 SRs.The JBI Levels of Evidence and Grades of Recommendation(2014)were used to rate the evidence quality.The first draft of the protocol included a total of 8 primary indicators,25 secondary indicators,and 111 pieces of evidence.5.Results of protocol revisions:After three rounds of Delphi consultations with 14 experts(13 experts in the second and third rounds),a total of 79 entries were deleted,2 entries were split,and 1 entry was added,and the final version of the protocol was formed,which comprised 8primary indicators,22 secondary indicators,and 35 pieces of evidence,with all entries having a recommendation rating of“strong”.6.Results of evidence translation:The entries in the protocol were translated into a flowchart for glycemic management in critically ill adult patients,adjusted IIPs,a frequency chart of glycemic monitoring,a glycemic monitoring record sheet,and reading materials for patients requiring blood glucose management,as well as a clearly defined training plan for conducting evidence-based practices for glycemic management.7.Results of protocol application:After the protocol was introduced into clinical practice,the proportion of ICU nurses who were"familiar and very familiar"with glycemic management in critically ill adult patients and who“agreed and strongly agreed”and"often and always did"increased significantly.ICU physician and nurses’evidence-based practice compliance was significantly improved,with 12 indicators showing a 100%increase in practice behavior adherence and 8 indicators showing an increase of 5.9%-66.7%.The mean duration of hyperglycemia(t=2.841,p=0.007),the mean duration after reaching the target glycemic range(t=-2.215,p=0.031),the incidence of glycemic control-related complications(~2=-2.215,p=0.038),and the need for continuous renal replacement therapy(CRRT)(~2=7.713,p=0.005)in patients were all improved after protocol application.The environment for glucose management practice was significantly improved in the pilot site,including staffing and restructuring of human resources,establishing or updating flows,introducing/developing new assessment tools and record sheets,introducing reading materials for patients requiring blood glucose management,and adding continuous glucose monitoring devices.Conclusion1.The“Evidence-based practice protocol for glycemic management in critically ill adult patients”protocol was developed based on the concept of Implementation Science(IS)and the background of the domestic practice of blood glucose management in critically ill patients,referencing to the methodology of evidence-based practice protocol construction and summarizing the latest and best evidence resources in this field at home and abroad.The protocol was revised and validated through several rounds of Delphi expert consultations,which can provide a reference for ICU professionals to carry out blood glucose management.2.The”Evidence-based practice protocol for glycemic management in critically ill adult patients”protocol was constructed based on the Rosswurm&Larrabee model of evidence-based practice changes,and the evidence included in the protocol could be introduced into clinical practice with good feasibility,suitability,clinical significance and effectiveness.3.Evidence utilization for glycemic management in critically ill adult patients can effectively enhance the knowledge,attitudes,and behaviors of ICU caregivers,increase their adherence to evidence-based practices,improve the status of glycemic management in ICU patients and optimize clinical practice contexts. |
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