Management of Mean Hyperglycaemia Levels in ICU Patients - Research Paper Example

? Management of Mean Hyperglycaemia Levels in ICU Patients and number submitted Table of Contents Introduction 4 Problem Statement 4 Literature Review 7 Hypothesis 12 Research Design 13 Role and Bias of Researcher 14 Target Population and Sampling Criterion 15 Method of Data Collection 16 Instruments of Data Collection 17 Description of the Data 18 Research Procedure 19 Data Analysis 20 Conclusion 21 References 24 Appendix A 29 This text is the official proposal for a research study offering insight into and solutions for the problem of improper nursing of victims of hyperglycemia (i-e blood glucose concentration over 180 dl/mg) in Intensive Care Units of medical facilities. The introduction is a restatement of the work of the first task of this project; it includes an explanatory description of the problem that is to be addressed through this research, of the justification for conducting this research and the rationale for the method and style of the research, of the role and limitations of the researcher, of the human subjects and sampling procedure and of the hypothesis of the study. The next part suggests the method(s) to be used to collect data. Then there is a description of the instrument of research followed by identification of the data to be collected. The proposal includes a comprehensive summary of the research procedure. A reflection over the formulation of the proposal concludes the project. Introduction Medical aid workers have been metaphorically referred to as angels in various records ranging from religious scriptures to war diaries. That money has a direct link to professional medical work means the impetus for helping others stay healthy has changed in its entirety across the developed world. Nursing is just another profession now though still slightly more noble than the average social service profession. But the degradation of prestige has had the effect of increasing numbers of nurses treating patients as clients of their institutions and miscalculating the sensitivity of their work. One problem which seems to be a manifestation of the aforementioned effect is the chronic inability of medical staff to cap the blood glucose concentration of hyperglycemia patients and to control their symptoms. There is enough evidence to believe that the aftereffects faced by sufferers of persistent hyperglycemia can be mitigated purely through better monitoring and management of the patients’ states of health in the Intensive Care Units. However, the exact causes of negligence, mishandling and below par medication of the patients are still not established; nor do we know exactly how these phenomena affect the patients’ organs and organ systems, which phenomenon occurs in what circumstances, and what is implied by each occurrence in medical terms. Problem Statement Diabetes mellitus has a unique association with other acute and chronic disorders such as congestive heart failure, chronic obstructive pulmonary disease, stroke, kidney failure, etc. During hospitalization, patients often encounter hyperglycemia. This is due to the increase in stress hormone circulation (Trence, Kelly, & Hirsch, 2003). It has been experimentally proven that high levels of glucose may have traumatic effects on the hemodynamic, immune and vascular systems. It has also been documented that the patients of hyperglycemia usually encounter subsequent health complications in the intensive care units (Golden, Peart-Vigilance, Kao, & Brancati, 1999). For instance, if the glucose levels are high after cardiac surgery, the chances of infection in the region of surgery increase (Zerr et al., 1997). Figure 1. Relationship between Hyperglycemia and Stress Hormone Circulation. Adapted from "Management of Hyperglycemia in the Hospital Setting" by Silvio E. Inzucchi, 2006. The New England Journal of Medicine, 18, p. 1904. The observations regarding the relationship of hyperglycemia with disorders of endocrine, cardiac and metabolic systems are not confined to patients of chronic diabetes (Capes, Hunt, Malmberg, & Gerstein, 2000). In a study by Umpierrez et al. (2002), it was proved that the patients who were newly diagnosed with hyperglycemia demonstrated a higher level of mortality rate in comparison to the chronic Diabetes Type II patients. It is still uncertain whether the glucose level is a mediator or an indicator for the aforementioned critical illnesses. In an intensive care unit, continuous and timely monitoring of glucose level to lower the mean hyperglycemic index is crucial. This can either be achieved through the administration of hypoglycemic drugs or an intensive administration of insulin. Type II Diabetes Mellitus or the non-insulin dependent diabetes mellitus (NIDDM) is associated with increased insulin resistance an addition to inadequate usage of insulin produced by the pancreatic cells (“National Diabetes Statistics, 2007 fact sheet,” 2008). This type of diabetes sometimes also involves insufficient production of the insulin hormone by the pancreatic cells. This type of Diabetes Mellitus affects 90-95% of the diabetics in the United States of America and is related to other risk factors or complications such as older age, physical inactivity, family history, obesity, past medical history, and the genetic factor of background determinations (Chowdhury 2003). The ethnicities that are at a higher risk of Type II diabetes include Hispanics, South Asians, and Afro-Americans (Hossain, Kawar, & El Nahas, 2007). Literature Review The risk factor of arrival of a patient in an intensive care unit with problems such as Myocardial infarction, stroke, critical illness, orthopedic surgery, coronary obstructive pulmonary disease or trauma, can be multiplied by the incidence of hyperglycemia (Wukich, Lowery, McMillen & Frykberg, 2010). The staff present at the intensive care unit can provide quality care in terms of aggressive insulin therapy (Schulman & Mechanick, 2012). This therapy can improve the outcomes of myocardial infarction, cardiac surgery and the overall effect of intensive care (Banning et al., 2010). However, the incidence of hyperglycemia in cardiac patients can lead to three major problems namely overall infection, mortality and deep wound infections. In the patients with stroke problems, hyperglycemia renders increased level of mortality (Cushman et al., 2010). It also highlights that if the blood sugar level is 120-145 mg/dl, the functional recovery could be worse. Moreover, in the case of both known diabetic and non-known diabetic patients with the blood sugar level greater than 140 mg/dl, the result can be strokes with greater mortality rate (Sarwar et al., 2010). Causes of hyperglycemia in Intensive Care Unit patients. According to Hassall and Butler-Williams (2010), the major causes of hyperglycemia in intensive care units include: 1. Administration of glucocorticosteroids 2. Insulin resistance 3. Exogenous catecholamines 4. Circulation of stress hormones 5. Lipolysis 6. Gluconeogenesis 7. Intravenous dextrose administration Glycemic targets in hospitalized patients. As indicated by the American Diabetes Association (2012), the blood sugar of a diabetic patient is greater than or equal to 126 mg/ dl when tested during fast. In this case, the target should be glucose level between 70-130 mg/ dl. In the same manner, in a hospitalized patient the blood sugar can be equal to or higher than 140 mg/ dl. In this case, the ideal level should be 110- 140 in patients that have undergone surgeries and are admitted in the intensive care units. Figure 2. Glycemic targets in hospitalized patients. Reprinted from “Management of hyperglycemia in the intensive care unit: when glucose reaches critical levels,” by Author Brady, V. 2013, Critical Care Nursing Clinics of North America, Volume(1), 9. Role of intensive insulin therapy in Intensive Care Units. To review the role of aggressive insulin therapy the study by Van Den Berghe et al (2001) can be put forward. The researchers in this study presented a hypothesis that the normalizing the blood sugar level with intensive insulin therapy may produce improvements in the hyperglycemic patient prognosis or resistance to insulin. This was a randomized control trial and in their study, they considered a patient to get aggressive insulin therapy if the blood glucose was greater than 110 mg/dl. They intended to maintain the level of 80-110 mg/dl throughout the research. The result was astonishing as the mortality rate reduced to 40%. Figure 3. Relative reduction in the mortality rate by adopting aggressive insulin therapy in critically ill patients. Reprinted from “Intensive Insulin Therapy in Critically Ill Patients,” by Van den Berghe, G. 2001, The New England Journal of Medicine, Volume (235), 1361 In another successful 17-year non-randomized trial by Furnary, Wu and Bookin (2004) confirmed the wonders of intensive insulin therapy in 4864 diabetic patients who underwent open-heart surgeries. In this study, they explicitly documented that the hyperglycemic episodes resulted in high level of hospital cost, deep sternal wound infections, longer length of hospital stay and even death. However, the continuous and intensive insulin therapy for three consecutive days after the cardiac surgery resulted in reduction of deep sternal wound infections by 66% and mortality rate by 57%. The ultimate goal of the researchers was to keep the glucose level below 150 mg/dl. Oral anti-hyperglycemic drugs and diabetic patients in Intensive Care Units. Diabetic patients are frequently prescribed oral anti-hyperglycemic drugs in an outpatient setting. However, it has been observed that the usage of these drugs in intensive care units is quite limited. The major reason behind this is the side effects associated with these drugs and the first pass mechanism that may give only a limited therapeutic outcome. Since the patients in intensive care units require immediate quality care by the nursing staff, insulin is the first line of choice. The most commonly used anti-hyperglycemic drug is Metformin (Christiansen et al., 2013). This drug can cause lactic acidosis and can lead to lactate production. The ultimate results are circulatory failure, renal failure and hypoxemia (Nye & Herrington, 2011). On the other hand, the drugs such as sulfonylureas stimulate the release of insulin in the body. However, the dosage and administration is limited to patients in which hypoglycemia has to be prevented and who can voluntarily take nutrition. Comparison of insulin therapy and anti-hyperglycemic drugs in Intensive Care Unit patients. The rapid onset of therapeutic effect of the insulin therapy makes it first line of choice in intensive care units by the nursing staff. Insulin responds in a timely manner to the dosage requirements. Hence, it can be used in almost all type of patients for the control of blood glucose in emergency. Insulin can be administered intravenously and subcutaneously depending on the titration ratio and treatment goal (Holman et al., 2009). Figure 4. Comparison of Insulin with Oral Hypoglycemic drugs. Reprinted from “Management of hyperglycemia in the intensive care unit: when glucose reaches critical levels,” by Author Brady, V. 2013, Critical Care Nursing Clinics of North America, Volume(1), 9. Continuous glucose monitoring in Intensive Care Unit. In a critical care unit or intensive care unit, the nursing staff gives close attention to the glucose level of a patient at all times. This is because the critically ill patients usually show signs of hyperglycemia especially when they reach a certain age (Finfer et al., 2009; Lange, 2010). It has been observed that tightly monitoring blood glucose may lead to hypoglycemic consequences in critically ill patients. The setback is that even minor episode of hypoglycemia can lead to coma and death. The use of continuous glucose monitoring system has increased over the past decade. This device monitors the interstitial glucose level every ten seconds. This device has microelectrodes that transmit current to the monitor that stores data every five minutes. Ideal plan of care for the nursing staff in Intensive Care Units. The steps that should be incorporated to the insulin therapy, anti-hyperglycemic drug administration and glucose monitoring are listed below: 1. Restoration of the body fluid volume (Kitabchi et al., 2001; Delaney, Zisman & Kettyle, 2000; Levetan & Fischmann, 2000) 2. Glucose and ketoacidosis management (Katzung, 2001) 3. Electrolyte replacement therapy (Fisher & Kitabchi, 1983) 4. Adjunctive therapy to prevent urinary tract infection, pneumonia, dehydration, foot infection, etc (Chang et al., 2007; Nesbeth, Orskov & Rosenthall, 2009). Hypothesis When the researcher is discussing the findings of the research, he is putting forward a picture of coherence or confusion, lifelessness or dynamicity, truth or falseness and ultimately he is making a final personalized statement. Still, the hypothesis statement is perhaps the most meticulously constituted part of any research project. In terms of specific aims and objectives the purpose of this research can be described as: Determining the effects of insulin and hypoglycemic drug therapy; and of continuous blood glucose concentration monitoring of Type II diabetic patients admitted to Intensive Care Units. A hypothesis statement follows from this description of objectives of the research asserting that “the mean hyperglycemia levels of Type II diabetic patients admitted to Intensive Care Units depend on the efficiency of insulin and hypoglycemic drug administration to the patient; and on continuous monitoring of the patient’s blood glucose concentration.” Research Design This research is classified as a quantitative study. Quantitative research approach is specialized in the examination of data in order to evaluate and prove the objectives and aims of the research. It also focuses on the justification of the proposed hypothesis. According to Creswell (2009), the research methodology of quantitative analysis and its research design focuses on the provision of systematic analysis of quantifiable sets of data. There are two ‘modes’ of quantitative research: longitudinal and cross-sectional. While the longitudinal method studies a few individuals with data collected over a time interval, the cross-sectional approach is employed when investigating elements varying over a large population. This study is categorized as a cross-sectional quantitative research because it will be conducted over a sample of the whole population of nurses dealing with hyperglycemia to investigate a predefined element. This is because the study hopes to identify areas of concern rather than investigate the development of a problem related to a specific target. The study aims to identify reasons for deficiencies in the care provided to Intensive Care Unit patients suffering from hyperglycemia. The research is important because there has long been an issue of hyperglycemia patients developing consequential cardiac complications because of the treatment provided in the Intensive Care Unit. The study hopes to identify shortfalls in the nursing procedures and practices employed by hospitals and hospital workers; and to subsequently devise a set of Standard Operating Procedures for ICU nursing of hyperglycemic patients. Role and Bias of Researcher Essentially, the role of the researcher in this study is catering to the hypothesis of the study; and coming up with a credible conclusion and a viable solution or explanation respectably for the problem identified in the hypothesis. However to accomplish these tasks the researcher has to expend time, effort and material resources on comprehensively defining the rationale behind conducting the research, clearly identifying the various aspects of the research, conceptualizing a strategy for the research, collecting and verifying data, drawing observations and conclusions; and suggesting recommendations. The researcher probably will not have enough monetary resources to collect complete data from relevant individuals all over the world and the study must be constrained to the United States. This fact is significant because the U.S. is not a definitive microcosm of the world as it is a developed country (Bell & Pavitt, 1997); the cumulative population of undeveloped countries is many times that of the advanced states. Another factor to be considered is that professionals participating in surveys usually do not interact openly with university students’ academic surveys and the information conveyed to the researcher may be of a lesser quality than what is potentially available. Target Population and Sampling Criterion The basic criterion to be used for sampling from the population of this study is probability sampling. However the target population will be divided into strata and the technique will employ systemic disproportionate representation of each stratum. The next paragraph explains how the target population of this study is to be sampled using this criterion. The population for this study comprises of all the nurses in the United States involved in caring for victims of Hyperglycaemia. The target population has been chosen as the nurses of the five thousand hospitals chosen for a quality-of-service survey by U.S. News and World Report (2013). The lower the score of a hospital in the Diabetes & Endocrinology category the greater will be the representation of nurses from that hospital in the survey; this is elaborated by the following table: Score (%) Representation (%) 0-10 100 10-20 90 20-30 80 30-40 70 40-50 60 50-60 50 60-70 40 70-80 30 80-90 20 90-100 10 Table 1. Disproportionate Sampling This means that all the nurses from hospitals scoring zero to ten percent will be selected while only ten percent of nurses from hospitals scoring ninety to hundred percent will be invited for the survey. The reason for this style of sampling is that the research hopes to identify shortfalls in the handling of Hyperglycaemia cases so that they can be addressed. The aim of the study is not to improve upon the existing best practices of controlling glucose levels. Hence there ought to be more representation of hospitals that do not employ efficient mechanisms of caring for Hyperglycaemia patients. Also the study neglects the frequency of the various types of deficiencies because that is not relevant to the objective of this research; besides incorporation of that factor would add to the workload of a research of this level and may lead to inefficiencies in conducting the research. The overall sample size can be reduced at the stake of increasing the margin of error using the following formula: n = N / (1+Ne2) where ‘n’ denotes the sample size, N is the population size and e is the margin of error. Method of Data Collection There will be two stages of data collection, both employing two methods of collecting data. The research may also have to be divided into two separate studies one of which would be inevitably less reliable then the other. This is because the researcher will attempt to use medical records from hospitals’ Intensive Care Units in the first part of the study. Any available records through contacting hospital administrations; on hospital, health service and Department of Health and Human Services’ websites shall be consulted to collect some of the data required in the research. After this a survey with specific questions for nurses will be conducted through phone and if necessary, in person. However there is a possibility that the researcher may not be able to gain access to many of the relevant databases of medical records of hospitals. In such a case an additional study will be conducted where no data is collected from hospitals’ records and all the information is acquired through asking questions from nurses. This is a measure to ensure the uniformity of accuracy of the whole collection of data. Instruments of Data Collection A software database is to be created for storing the data collected from ICU notes of Hospitals’ medical records. This database will only store numeric values which would be used later for scientific analysis. If numeric data is collected through a direct survey of the nurses the data will be personally entered into the database. This data may also be analyzed for a statistical analysis using software such as the “Statistical Package for Social Science (SPSS)” etc. It will be requested of the nurses invited to participate in the survey to fill out forms after careful deliberation and to thereafter return them. The nurses will be provided forms in printed form or in electronic form using text messages or emails. Only in case a nurse insists on not filling out any form should questions of the survey be asked on the phone or in person and recorded on the appropriate form. The form to be used for data collection from nurses is presented in Appendix A of this text. Description of the Data As discernable from the table in Appendix A there are primarily two sets of data, one focusing on the nurses’ periodicity of monitoring patients’ blood glucose concentration and administering drugs; and the other examining the common post-admittance health issues of ICU hyperglycemia patients. The second set of data provides additional insight into patient care issues and does not address the hypothesis of the study. The data is constituted by the following types of information: the commonly used concentrations and dosages of different types of hypoglycemic drugs and insulin; the periodicity of administering these drugs; the periodicity of checking patients’ blood glucose levels; the frequency of occurrence of different types of health complication during or immediately after the patients’ time in the ICU; and the efficiency of caregivers in identifying each type of complication. The analysis of the study is based on the comparison of acquired information about nursing practices in hospitals with the recommended procedures. The following table gives the set of dependant and independent variables for this study: Independent Variable Dependant Variable Type of chemical Periodicity of administering or monitoring Dosage and concentration Type of complication Frequency of occurrence Nurses’ efficiency in spotting the symptoms Table 2. Dependant and Independent Variables Research Procedure The problem of subsequent health issues of under-care hyperglycemia patients has been long documented but never addressed by a recognized medical researcher. In elementary terms this research is an effort to identify loopholes and deficiencies in the customary practices of caring for hyperglycemia patients in Intensive Care Units of hospitals. As is evident from the name of the disease, the nurse’s role in caring for this type of a patient is keeping the patient’s hyperglycemic index under control and mitigating it. The researcher will ask nurses from hospitals all across the U.S. about their practices in looking after hyperglycemia patients in ICU wards. Nurses from lower rated hospitals are deliberately being granted more representation among the research subjects because their hospitals would provide a more holistic picture of where the medical staff lacks in looking after hyperglycemia victims. The data will be collected using various resources such as hospital administrations, electronic medical record books as well as direct conversation with nurses. This data will include two main subjects of information: Nurses’ role in monitoring patients’ blood sugar levels and administering prescribed drugs punctually, characterization of frequently occurring subsequent health complications for hyperglycemia patients and the problems in diagnosing the symptoms. The latter part of the study is not scientific nor does it cater to the main objectives and hypothesis of the research. Once the data is accumulated it can be analyzed in a number of ways including comparing the common nursing practices regarding ICU hyperglycemia patients with the recommended manner of caring for the patients. The results of the study could be used to devise a concise set of Standard Operating Procedures specifically formulated for nurses of hyperglycemia patients in the ICU. Data Analysis The data collected through researching may be analyzed in a number of ways including statistical analyses and data mining. However the principle approach to the analysis of the accumulated data should be Explanatory Data Analysis. The primary technique for identifying the trends, patterns and outliers of the nursing data would be the use of the S programming language from Bell labs or another similar software application in the case of unavailability. The computation is necessary because it is impossible to perform substantial comparisons of such a fairly high volume of data using the brain. The comparisons are represented by the following tasks: comparing the periodicities of recording of glucose concentrations and administration of hypoglycemic drugs, with prescribed standard periodicities; comparing the concentrations and dosages of these drugs with those prescribed by the doctors; comparing the frequencies of occurrence of the various types of subsequent health complications; and comparing diagnosis times of several health complications with their respective frequencies of occurrence to provide a good measure of the immediacy of the need to deal with each problem. In addition to carrying out a comparative study it is also useful to find out the standard variation of each type of data which would give an idea of how closely the medical practices in ICUs are converging to a normal. The research will also give the medical institutions information about which post-hyperglycemia complication nurses find the hardest to spot. And if a system of further work in line with this approach is established it will act as a feedback mechanism for the medical institutes to mould the training regimens of the nurses according to the necessities and shortfalls of the nursing profession as identified by such studies. This research’s data will also provide a detailed insight into the typicality of nursing issues of the different classes of health facilities as derived from their ratings in the U.S. News and World Report survey. Finally, the clear definition of dependant and independent variables means that it is possible to model the resultant data of the study mathematically and generate graphs, charts etc to better help the understanding of observers and analysts using stochastic linear modelling, for example; which is compatible with this kind of data collection, classification and distribution. Conclusion The research proposal is hereby complete and may be put forward for a practical study based on it. This proposal is of course a theoretical briefing about the academic way of researching a very particular topic. It is intended to be a guideline for the specific tasks to be performed in carrying out a research study on the management of mean hyperglycemia levels of patients in ICUs. While the proposal is intended to be not lengthy nor incomprehensive or inconclusive, it is limited in scope anyhow by the project’s academic nature and by the requirements of this course and the level of study. Also the project’s uniqueness is emphasized in the fact that it proposes a quantitative study while research projects regarding an area dealing strictly with human interactions, such as nursing, are most usually qualitative. While there may be some value in utilizing this proposal for some research, there certainly was a lot of useful learning during the performance of this project. It taught me about the value of choosing the right topic for a research: it is what determines the experience in drafting the rest of the proposal. It seems a bit presumptuous to try to adapt a yet-obscure topic for a research study of this level. Hence the only way I can really make a difference in the progress of the collective knowledge of the intellectual and scientific fraternity is by furthering exploration into a subject that is already under the spotlight of the academic society, though that does not mean that the research project proposed is of little value. The selection of material for literature review might well have been much more meticulous than it was for this project. Any future research proposals I present shall be reviewed and revised as drafts before a finalized description of the fundamental subject of research is adapted. Also, identification of all the dependant and independent variables for the research is a concentration-intensive part of the construction of the proposal. Similarly selecting, arranging and paraphrasing the prominent and essential parts of the procedure for research are not a simply done. However there were a lot of interesting aspects of the project. Though I have already stated in this paragraph that the choice of topic of research is vitally important, it so happens that one can always construct the proposal from a perspective that yields valuable insight. The real value of the proposal can only be correctly established when it is put to test through work proceeding on the proposed study. However there is plenty of recognized academia including doctorates and experienced research professionals who might offer reviewing the proposal. I am willing to take in any suggestions, blunt criticisms as well as identification of personal shortfalls by respectable professors on this proposal as at this stage of my career my focus is on learning and improving with the highest gradient possible. I do hope that the proposal, even after a major revision as necessary, gets picked up by another student of the field of nursing before I start planning my capstone dissertation project. However if the proposal attains acceptable status by the faculty’s standard I hope to start work on the practical part myself. References American Diabetes Association. (2012). Diabetes Statistics. http://www.diabetes.org/diabetes-basics/diabetes-statistics/. Banning, A. P., Westaby, S., Morice, M. C., Kappetein, A. P., Mohr, F. W., Berti, S., ... & Serruys, P. W. (2010). Diabetic and Nondiabetic Patients with Left Main and/or 3-Vessel Coronary Artery Disease: Comparison of Outcomes with Cardiac Surgery and Paclitaxel-Eluting Stents. Journal of the American College of Cardiology, 55(11), 1067-1075. Bell, M., & Pavitt, K. (1997). Technological accumulation and industrial growth: contrasts between developed and developing countries. Technology, globalisation and economic performance, 83-137. Capes, S. E., Hunt, D., Malmberg, K., & Gerstein, H. C. (2000). Stress hyperglycaemia and increased risk of death after myocardial infarction in patients with and without diabetes: a systematic overview. The Lancet,355(9206), 773-778. Chowdhury, T.A. (2003). Preventing diabetes in South Asians. British Medical Journal. 327, 1059-1060. Chang, K., Davis, R., Birt, J., Castelluccio, P., Woodbridge, P., & Marrero, D. (2007). Nurse Practitioner-Based Diabetes Care Management. Disease Management & Health Outcomes, 15(6), 377-385. Christiansen, C. F., Johansen, M. B., Christensen, S., O'Brien, J. M., Tonnesen, E., & Sorensen, H. T. (2012). Type 2 diabetes and 1?year mortality in intensive care unit patients. European journal of clinical investigation. Creswell, J.W. (2009). Research Design Qualitative, Quantitative, and Mixed Methods approaches Third Edition, SAGE Publications, Inc, pp. 296 Data retrieved from http://www.sagepub.com/books/Book232401 Cushman, W. C., Evans, G. W., Byington, R. P., Goff Jr, D. C., Grimm Jr, R. H., Cutler, J. A., ... & Ismail-Beigi, F. (2010). Effects of intensive blood-pressure control in type 2 diabetes mellitus. The New England journal of medicine, 362(17), 1575. Delaney, M., Zisman, A., & Kettyle, W. (2000). Acute complications of diabetes. Endocrinology and Metabolism Clinics, 29, 683-705 Finfer, S., Chittock, D. R., Su, S. Y., Blair, D., Foster, D., Dhingra, V., ... & Ronco, J. J. (2009). Intensive versus conventional glucose control in critically ill patients. N Engl J Med, 360(13), 1283-1297. Fisher, J., & Kitabchi, A. (1983). A randomized study of phosphate therapy in the treatment of diabetic ketoacidosis. Journal of Clinical Endocrinology and Metabolism, 57, 177-180 Furnary, A. P., Wu, Y., & Bookin, S. O. (2004). Effect of hyperglycemia and continuous intravenous insulin infusions on outcomes of cardiac surgical procedures: the Portland Diabetic Project. Endocrine Practice, 10, 21-33. Data retrieved from http://aace.metapress.com/content/4nyljy82ca90afu3/ Golden, S. H., Peart-Vigilance, C., Kao, W. H. L., Brancati, F. L. (1999). Perioperative glycemic control and the risk of infectious complications in a cohort of adults with diabetes. Diabetes Care; 22:1408-14. Hassall, S., & Butler-Williams, C. (2010). Blood glucose monitoring in critically ill patients. British Journal of Neuroscience Nursing, 6(7), 342. Holman, R. R., Farmer, A. J., Davies, M. J., Levy, J. C., Darbyshire, J. L., Keenan, J. F., & Paul, S. K. (2009). Three-year efficacy of complex insulin regimens in type 2 diabetes. New England Journal of Medicine, 361(18), 1736-1747. Hossain, P., Kawar, B., & El Nahas, M. (2007). Obesity and diabetes in the developing world—a growing challenge. New England Journal of Medicine,356(3), 213-215. Katzung, B. (2001). Basic & clinical pharmacology (8th ed.). New York: McGraw-Hill Kitabchi, A., Umpierrez, G., Murphy, M., Barrett, E., Kreisberg, R., Malone, J., et al. (2001). Management of hyperglycaemic crises in patients with diabetes. Diabetes Care 24, 131-153. Lange, V. Z. (2010). Successful management of in-hospital hyperglycemia: the pivotal role of nurses in facilitating effective insulin use. Medsurg nursing: official journal of the Academy of Medical-Surgical Nurses, 19(6), 323. Levetan, C, & Fischmann, M. (2000). Acute complications of diabetes: Hospital management of diabetes. Endocrine and Metabolism Clinics 29, 745-770 “National Diabetes Statistics, 2007 fact sheet”. (2008). National Institute of Diabetes and Digestive and Kidney Diseases. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health. Nesbeth, H., Orskov, C., & Rosenthall, W. (2009). Breaking down the barriers to good glycaemic control in type 2 diabetes: a debate on the role of nurses.European Diabetes Nursing, 6(1), 29-33. Nye, H. J., & Herrington, W. G. (2011). Metformin: the safest hypoglycaemic agent in chronic kidney disease?. Nephron Clinical Practice, 118(4), c380-c383. Sarwar, N., Gao, P., Seshasai, S. R., Gobin, R., Kaptoge, S., Di Angelantonio, E., ... & Danesh, J. (2010). Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies. Lancet, 375(9733), 2215-22. Schulman, R. C., & Mechanick, J. I. (2012). Metabolic and nutrition support in the chronic critical illness syndrome. Respiratory care, 57(6), 958-978. Trence, D. L., Kelly, J. L., & Hirsch, I. B. (2003). The rationale and management of hyperglycemia for in-patients with cardiovascular disease: time for change. Journal of Clinical Endocrinology & Metabolism, 88(6), 2430-2437. U.S. News & World Report LP. (n.d.). U.S. News Best Hospitals 2013-14. US News. Retrieved November 18, 2013, from http://health.usnews.com/best-hospitals/rankings Umpierrez, G. E., Isaacs, S. D., Bazargan, N., You, X., Thaler, L. M., & Kitabchi, A. E. (2002). Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. Journal of Clinical Endocrinology & Metabolism, 87(3), 978-982. Van Den Berghe, G., Wouters, P., Weekers, F., Verwaest, C., Bruyninckx, F., Schetz, M., ... & Bouillon, R. (2001). Intensive insulin therapy in critically ill patients. New England journal of medicine, 345(19), 1359-1367. Data retrieved from http://www.nejm.org/doi/full/10.1056/NEJMoa011300 Wukich, D. K., Lowery, N. J., McMillen, R. L., & Frykberg, R. G. (2010). Postoperative infection rates in foot and ankle surgery: a comparison of patients with and without diabetes mellitus. The Journal of Bone & Joint Surgery, 92(2), 287-295. Zerr, K.J., Furnary, A.P., Grunkemeier, G.L., Bookin, S., Kanhere, V., Starr, A. (1997). Glucose control lowers the risk of wound infection in diabetics after open heart operations. The Annals of Thoracic Surgery, 63:356-61. Appendix A A tabular representation of the questionnaire to be used for data collection from nurses. Question Exact Interval Approximately Every 3-6 hours Approx. Every 6-12 hrs Approx. Every 12-24 hrs Usual Concentration and Dosage How often is the glucose level of non-emergency chronic hyperglycemia patients in the ICU monitored? N/A How often is insulin administered to these patients? How often is exenatide administered to a patient on it? How often is liraglutide administered to a patient on it? How often is pramlintide administered to a patient on it? How often are oral hypoglycemic agents administered to a patient on them? How often do patients develop this complication during or immediately after their time in the ICU? Cardiovascular Complications Kidney Complic. Neurological Complic. Retina Damage Diabetic Neuropathy Usually Very often Sometimes Rarely How quickly are caregivers able to spot symptoms of this complication? Dangerously late Late Early Immediately Read More