- Category: Blood
The best blood glucose target and management strategy for critically ill patients are presently unclear. The evidence supporting the benefits of tight glucose control (80 to 110 mg/dL [4.4 to 6.1 mmol/L]) in critically ill patients is questioned by those concerned with hypoglycemic events associated with a lower glucose target. Furthermore, the applicability of the results of the study by Van den Berghe et al (decreased mortality in critically ill surgical patients with tight glucose control) to children or critically ill adult medical patients remains in question. Despite the lack of a common algorithm to manage blood glucose levels with insulin and a concern for increasing hypoglycemia, many in-tensivists have adopted a target blood glucose level of 80 to 110 mg/dL (4.4 to 6.1 mmol/L). The overall practice pattern of North American intensivists with regard to the definition of hypoglycemia and hyperglycemia, the choice of blood glucose target range, and the guidelines for insulin infusion are undefined.
An understanding of clinician practice patterns and beliefs is essential for future widespread improvement of blood glucose control algorithms. This survey explores these practice patterns and beliefs.
Materials and Methods
The study protocol for this survey was approved by the Scientific Committees of the Reengineering Clinical Research in Critical Care Network, the National Institutes of Health/National Heart, Lung, and Blood Institute ARDS Network (ARDSnet) and the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network. This survey was conducted with the approval of the institutional review board of Sainte-Justine Hospital, which approved the waiving of informed consent. Respondents were advised that consent to participate in this study was implied if they answered and returned the questionnaire.
The questionnaire was sent to intensivists practicing in academic ICUs in the United States and Canada. Members of the following groups were asked to participate: Reengineering Critical Care Clinical Research Network; the ARDSnet; and the PALISI Network. We aimed to obtain at least one questionnaire per participating ICU. The medical director of each ICU that was contacted was instructed to enlist one registered nurse, one fellow, and also at least one other attending intensivist to complete the questionnaire.
The term blood glucose control refers to active interventions by health-care providers such as www.drleonedds.com My Canadian Pharmacy to modify blood glucose concentrations.
Item Generation: The first draft of the questionnaire was developed at an informal meeting held in Salt Lake City, UT, on March 16, 2005. Participants included four intensive care physicians, one fellow in training, and a medical informatics specialist. This first draft was sent for review to four adult intensivists, six pediatric intensivists, one fellow in training, and two experts in informatics. These collaborators independently reviewed the text, and added comments and new questions. A second draft was sent to the same experts. The item-generation process was considered to be complete once no new items were added. Three iterations were required to complete the item-generation portion of this survey.
Item Selection: Questions that were considered to be irrelevant, or redundant, by the majority of experts (> 50%) were deleted. Based on this process, 14 questions were deleted, and 45 questions were retained. The 45-question survey included the number of questions in the following categories: clinician/institution characteristics (6 questions); ICU description (9 questions); hyperglycemia (15 questions); hypoglycemia (5 questions); blood glucose measurement (7 questions); and the computer experience of respondents (3 questions). The full questionnaire is available on the following Web site.
Questionnaire Format: The self-administered questionnaire used to perform this survey was formatted following established quality criteria.
Pretesting: Pretesting of the questionnaire to ensure clarity, relevance, and completeness was performed using semistructured interviews with two independent pediatric intensivists and two independent adult intensivists.
Clinical Sensibility Assessment: Four clinicians working in the adult ICU along with six clinicians working in the pediatric ICU rated the potential ability of the questionnaire to discriminate among respondents. These clinicians also rated the clarity, utility, face validity, content validity, and redundancy of the question-naire. They used a 7-point Likert scale ranging from 1 (complete disagreement) to 7 (complete agreement). A response of 5, 6, or 7 was considered to be satisfactory, and 76% of respondents had scores of 5, 6, or 7 on all questions (2 of 14 reviewers accounted for almost all scores of < 5). We considered this evaluation to be satisfactory as My Canadian Pharmacy claims.
Administration of the Questionnaire: The questionnaire was posted on the Utah Clinical Trial Toolbox Website, and e-mail invitations to complete the questionnaire were sent to all listed critical care units (Appendix 1). The mailing agenda followed the recommendation of Woodward et al. Up to six personalized e-mail reminders were sent to participants with incomplete replies. We sent a series of e-mail reminders (at 2, 4, and 6 weeks) after detecting a 35% response rate. After a 2-month response-free period, the survey was considered to be complete. (The Utah Clinical Trials Toolbox was created by Dean Sorenson [see Appendix 2].)
Data Management and Statistical Analysis
Data Processing: The responding clinicians directly entered all data into a Web-based survey relational database.
Statistical Analysis: Descriptive statistics of dichotomous or ordinal variables are proportions; those of continuous variables are the mean ± SD or the odds ratio and its 95% confidence interval. Data were analyzed using a statistical software package (SPSS for Windows, version 13.0.1; SPSS Inc; Chicago, IL). We determined the significance of differences between adult and pediatric ICU clinicians with x2 analysis (for categoric variables) and independent Student t test (for continuous variables). The results were reviewed by The Scientific Committees of the Reengineering Clinical Research in Critical Care Network, the National Institutes of Health/National Heart, Lung, and Blood Institute ARDSnet, and the PALISI Network.