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EBP ReportTeam OutlawSusan Outlaw, Melissa Ashley, Mary Holston, Beverly McMillionAuburn MontgomeryEBP Report Team OutlawType One Diabetes Mellitus (DM), also called insulin dependent diabetes mellitus (IDDM), is usually first diagnosed in childhood but can also present in adulthood. The etiology of Type One DM is an “autoimmune destruction of the pancreatic beta cells, resulting in lack of insulin secretion” (Adams & Holland 2014, p. 680). The symptoms include hyperglycemia, fatigue, excessive urination, excessive thirst, weight loss, and increased hunger (Adams et al.). The treatment for Type One DM is insulin replacement therapy, proper diet, and exercise. Type Two Diabetes Mellitus (DM) presents in middle-aged adults and is commonly “referred to as age-onset diabetes or maturity-onset diabetes” (Adams & Holland 2014 p. 683). The exact etiology is unclear, but it results from insulin resistance or not enough insulin produced by the pancreas. The symptoms include increased thirst, frequent urination, increased hunger, weight loss, fatigue, blurred vision, and slow healing of sores or infections. Risk factors include obesity, inactivity, family history, age, and ethnicity. Treatment of Type Two DM includes oral medication, proper diet, exercise, and in some cases, insulin replacement therapy is required (Adams et al.). Both Type One and Type Two DM are similarly diagnosed. According to American Diabetes Association, methods such as hemoglobin A1C, fasting plasma glucose, and oral glucose tolerance test are utilized to determine diagnosis. If uncontrolled, both Type One and Type Two DM can result in complications including heart disease, neuropathy, nephropathy, bacterial infections, fungal infections, impaired vision, impaired hearing, osteoporosis, amputations, dementia, and even death. In fact, diabetes is the seventh leading cause of death in the United States at this time (Adams & Holland 2014, p. 680). This statistic alone shows the need for researching the effectiveness of insulin protocols in regards to maintaining serum blood sugar for patients at high risk for uncontrolled diabetes. The steps in the evidence-based process (EBP) will be utilized to guide a team in finding the best evidence to address a focused question. A case study provides information for development of the focused question. The case study involves Amy, a 36 year old Caucasian female, admitted to the hospital and placed on an insulin drip due to her blood sugar of 300. Amy is an overweight smoker, a heavy drinker, and is nonadherent to her home insulin regimen. The hospital insulin drip protocol is to maintain serum blood sugar between 70 and 110 mg/dl. Recently a pilot research project indicated that a mean serum blood sugar for patients discharged from cardiac care units was 148. The nurses caring for Amy question if the current protocol ranges are appropriate.Patient Focused QuestionThe purpose and goal of the query is to determine if the current hospital insulin protocol to maintain serum blood glucose between 70 and 110 mg/dl is effective for Amy. The focused question is: What is the highest level of evidence available in determining if the hospital’s current insulin drip protocol to maintain serum blood sugar levels between 70 and 110 mg/dl is effective for a 36 year old Caucasian female who is an overweight smoker, heavy drinker, and non-adherent to her home insulin regimen and has been admitted to the hospital with blood sugar of 300 and placed on an insulin drip?Targeted ResourcesThe EBP team decided to perform a systematic search for the highest level of evidence available related to the focused question in databases including PubMed, CINAHL, Cochrane, Medline, Google Scholar, and printed textbooks as well. These sources were chosen in order to access meta-analyses, systematic reviews, evidence-based reviews, randomized control trials, and textbook information. We began the search in the Cochrane database because it contains the highest quality meta-analyses and systemic reviews of random control trials. From there, we worked our way down the evidence pyramid to continue the search for relevant quantitative and qualitative articles.The SearchAfter deciding which databases would be used in the search for best evidence, the team developed a focused question to guide the search. This question was developed using the PPAARE method (see Table 1). The problem is that we are unsure if the current hospital insulin drip protocol to maintain serum blood glucose between 70 and 110 mg/dl is effective for this patient. The patient is a 36 year old white female whom is non-adherent to her home insulin therapy, overweight, a heavy drinker and tobacco user admitted to the hospital with hyperglycemia and placed on an insulin drip. The action is to determine if the hospital insulin drip protocol to maintain the blood sugar between 70-110mg/dl is appropriate for this patient. The result will be to collaborate with the physician to establish an individualized and effective blood sugar protocol for this patient to achieve optimal outcomes for the individual patient. The evidence is valid, relevant and the highest available. We omitted any information on pediatric patients. The focused question is: What is the highest level of evidence available in determining if the hospital’s current insulin drip protocol to maintain serum blood sugar levels between 70 and 110 mg/dl is effective for a 36 year old Caucasian female who is an overweight smoker, heavy drinker, and non-adherent to her home insulin regimen and has been admitted to the hospital with blood sugar of 300 and placed on an insulin drip? Table 1 PPAARE Question for Case Study Focused Query QuestionPPAARE ComponentCase ExampleAlternate Search WordsExcluded WordsProblemIs the hospital insulin drip protocol effective for patient?Efficacy of insulin protocol, diabetes, treatmentPatientNon-adherent diabetic, middle aged, Caucasian woman, overweight, tobacco & alcohol user admitted to the hospital with blood sugar of 300 and placed on an insulin dripNon-compliant, white obese woman, smoker, drinker, risk factors, middle-agedPediatricActionMaintain realistic blood sugar control while in hospitalBlood glucose monitoring, hyperglycemia, insulin, glycemic controlAlternativePatient ResultsEstablish individualized blood sugar protocol to achieve optimal outcomeEffective blood sugar control, optimal outcomes, decrease complications, perceptions, experiencesLevel of EvidenceHighest available evidenceMeta-analysis, systematic reviews, peer reviewed, RCT’sRelevant EvidenceThe first article listed on the relevance table (see Table 2) was a meta-analysis of guidelines for the use of an insulin infusion in management of hyperglycemia in critically ill patients. Jacobi et al. (2012) evaluated available literature on safe and effective insulin infusion therapy while hospitalized. The review focused on studies that relate to maintaining the blood glucose levels between 150-180mg/dl. The analysis suggests the regimen and monitoring system be designed to detect and avoid hypoglycemia (blood glucose <70mg/dl), as well as minimizing glycemic variability. The conclusions are not final but suggest patients do benefit from maintaining blood glucose levels between 150-180mg/dl (Jacobi et al.).The next relevant source (see table 2) was an evidence-based review of in-depth interviews performed by experienced healthcare providers specializing in diabetes. The interviews were performed to determine experiences and perceptions of type 1 and type 2 insulin dependent diabetic patients regarding self-monitoring of blood glucose. Findings of Hortensius et al. (2012) were suggestive that healthcare providers primarily focus on strict glycemic control and do not consider factors that affect blood glucose monitoring nor patient’s quality of life in regards to strict glycemic control. Further suggestions indicate the need to work together with patients and include patients’ goals and needs in order to individualize plans and improve patients’ outcomes overall.The third source was a randomized control trial. Findings suggest maintaining blood glucose levels between 80-110 mg/dL improve clinical outcomes in critically ill patients. Data was collected from 52 patients in the medical intensive care unit (MICU) who were placed on IIP (Insulin Infusion Protocol). Nurses in the medical intensive care unit implemented strict glycemic control in critically ill patients that received IIP and adhered to detailed insulin dosing instructions. The results showed safe and effective improvement in glycemic control in critical ill patients (Bailey et al., 2004). The last relevant article was a case controlled study to determine the safety and efficacy of continuous insulin infusion (CII) in non-intensive care unit (ICU) settings. The study is an analysis of 200 consecutive patients receiving CII admitted to general medical-surgical units at Emory University Hospital with a target blood glucose (BG) less than or equal to 180 mg/dL. The recommended BG target range for ICU patients was 80-100 mg/dL. The study suggests an increase risk of severe hypoglycemia and mortality with tight glycemic control BG target of 80-110 mg/dL. This study also suggests the use of maintaining BG levels between 140-180 mg/dL during insulin therapy of non- ICU patients. The study also indicated maintaining BG levels between 140-180 mg/dL is safe and effective on non-ICU (Smiley et al. 2010).Table 2 Relevance of EvidenceEvidence Citation (APA)LevelofEvidenceResearchDesignPurpose/Question(s)/HypothesisPopulation/Sample/Inclusion and exclusion criteria describedData CollectionMethod(s)Data AnalysisMethod(s)Findings and ConclusionsJacobi, J., Bircher, N., Krinsley, J., Agus, M., Braithwaite, S., Deutschman, C., … Schunemann, H. (2012). Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. Critical Care Medicine, 40(12), 3251-3276. DOI: 10.1097/CCM.0b013e3182653269. Retrieved from: evaluate the literature and identify important aspects of insulin therapy that facilitates safe and effective infusion therapy for a defined glycemic end point.Adult medical/surgical ICU patients and subsets of neurologic injury, traumatic injury, and cardiovascular surgery. Included discussion on IV insulin and SQ when possible. Excluded other hypoglycemic & antidiabetic drugs. Did not evaluate articles with insulin a component of other therapies.Clinical question to analyze data base searchesRevMan & GRADEPro software, External peer review“Study not definitive, suggestions in this article provide structure for safe and effective use of this therapy that should be tailored for the individual patient.” (abstract)Bilo, H.J.G., Hortensius, J., Jaap, J., Kars, M.C., Kleefstra, N., & Wierenga, W. S. (2012). Perspectives of patients with type 1 or insulin-treated type 2 diabetes on self-monitoring of blood glucose: A qualitative study. BioMed Central Public Health, 12:167. doi: 10.1186/1471-2458-12-167. Retrieved from: investigate patients’ perspectives of self-monitoring of blood glucose and all relevant aspects influencing SMBG in patients with type 1 and insulin treated type 2 diabetes13 patients with type 1 diabetes from outpatient clinic and 15 patients with type 2 diabetes from general practices, treated with insulin, over the age of 18, Dutch speaking, differing in age, gender, living status, education, type of diabetes, insulin therapy, and employment.In-depth interviews transcribed verbatim using Grounded Theory ApproachTape recorded transcribed MAXqda 2007 in 3 phases of coding peer reviewedBlood glucose levels with strict ranges while maximizing patients’ quality of lifeBailey, V., Dziura, J., Goldberg, P., Halickman, J., Inzucchi, S., Lee, M., Lee, S., Sherman, R., & Siegel, M. (2004). Implementation of a safe and effective insulin infusion protocol in a medical intensive care unit. Diabetes Care, 27(2), 461-467. doi: 10.2337/diacare 27.2461. Retrieved from: provide a safe and effective IIP that allows for strict glycemic control in critically ill patients.200 Adult medical intensive care patientsClinical variables included age, sex, race, height, weight, history of diabetes, reason for ICU admission, and Acute Physiology and Chronic Health Evaluation II (APACHE II) score (5). And clinical interventions from active patients chart and MICU nursing records.Blood glucose values between patient groups were compared using the Student’s t test and Wilcoxon rank-sum test.The nurse- implemented IIP is safe and effective in improving glycemic control in critically ill patients.Smiley, D., Rhee, M., Limin, P., Roediger, L., Mulligan, P., Satterwhite, L.,…Umpierrez, G. (2010). Safety and efficacy of continuous insulin infusion in noncritical care settings. Journal of Hospital Medicine: An official publication of the society of hospital medicine. 5(4), 212-217. doi: 10.1002/jhm.646 Retrieved from: determine and evaluate the safety and efficacy of CII in non ICU settingAdult, Medical unit history of diabetes, mean glucose 323 mg/dlMale and female (age 52 +/- years) admitted to general medical unit with blood glucose > 200Retrospective analysis of 200 consecutive patients receiving CIIContinuous insulin infusion is effective in improving glycemic control on non surgical units with a blood glucose target <180.Evidence AppraisalA critical step in the EBP process is appraisal of evidence for trustworthiness and validity. One relevant qualitative study was appraised for trustworthiness (see Table 3.1). Our EBP team concluded that this qualitative study is valid and trustworthy. The purpose of the study was introduced clearly in the background section. The methods for sampling, gathering data, and analyzing the data were clearly detailed in the text, and were ethical and appropriate. Steps were taken to ensure credibility as well as objectivity was maintained during the study. The results indicate that the data gathered during the interviews was transcribed verbatim, which further establishes objectivity and unbiased findings. Multiple direct quotations were included in the interpretations, which further supports validity and trustworthiness. The discussion section includes logical explanations of findings. The conclusions relate well to the purpose of the research and are logical in relation to the findings and interpretation of findings. Table 3.1Questions to Establish Trustworthiness of a Qualitative StudyCONTENTQUESTIONSAPPRAISAL\check one boxAuthor’s names, credentials, affiliations, and conflict of interestBilo, H.J.G., Hortensius,J., Jaap, J., Kars, M.C., Kleefstra, N., & Wierenga, W.S.Diabetes Centre, Isala Clinics, Dokter Spanjaardweg 11, PO Box 10400, 8000,GK Zwolle, the Netherlands.Nursing Science, University Medical Center, Heidelberglaan 100, Utrecht, the Netherlands.Clinical Psychology, Meander Medical Center, Ringweg Randenbroek 110, Amersfoort, the Netherlands.Department of Internal Medicine, University Medical Center, Hanzeplein 1,Groningen, the Netherlands.Medical Research Group, Langerhans, p/a Dokter Spanjaardweg 11, Zwolle, the Netherlands.Faculty of Health, Welfare and Sports, Inholland University of Applied Sciences, Boelelaan 1109,Amsterdam, the Netherlands.Jelly Meyer from the Dutch Diabetes Association and Jolanda Hensbergen, diabetes specialized nurseAre the authors’ credentials and educational background appropriate to conduct this type of study? yesAre the authors affiliated with an educational program, health institution, or practice setting? Do the authors report a conflict of interest? Yes, no__x__Strength_____Limitation_____Not evident_____Not applicableFunding source(s)The authors acknowledge Sanofi Aventis for the financialsupport. Furthermore, the study was supported by a grant from the DutchDiabetes Research Foundation.Does the funding source have a vested interest in a beneficial outcome of the study? yes_____Strength__x__Limitation_____Not evident_____Not applicablePurposeTo investigate patients’ perspectives of self-monitoring of blood glucose and all relevant aspects influencing SMBG in patients with diabetes.Is the intent of the study clearly stated? yesIs the phenomenon being investigated identifiable? yesIs the population identifiable? yes___x__Strength_____Limitation_____Not evident_____Not applicableResearch questions“What does it mean to you to perform SMBG?” (p. )“Variety in SMBG performance in daily practice” (p. )Are the research questions in alignment with the intended purpose? yesIs the phenomenon under study identifiable in a broad research question? yes_x____Strength_____Limitation_____Not evident_____Not applicableQualitative approachIs the rationale for using a qualitative approach explained? Yes, to explain factors which affected the patients perspectives of SMBGIs the qualitative approach in alignment with the intended purpose? (e.g., ethnography, biography, phenomenology, case study, grounded theory) Yes__x___Strength_____Limitation_____Not evident_____Not applicableSample 28 pts total, DM1 from outpatient clinic of hospital in Netherlands & DM2 from general practice in same area. Could have led to selection bias because participants were ask to be in study by their PCP but included a wide diverse population.Was a sampling method or multiple methods used to identify participants who could inform the study? (e.g., purposive sampling, snowball or network sampling, theoretical sampling)Purposive sampling_x__Strength_____Limitation_____Not evident_____Not applicabl3Eligibility criteria: diagnosis of Type 1 or 2, treatment with insulin, SMBG for at least a year, Dutch speaking, over age of 18.How did the researchers attempt to gain variation within the sample? Stated “as much variation as possible”Were the inclusion and exclusion criteria clearly described, and were they appropriate for the purpose study? yesWas the inclusion and exclusion criteria clearly described, and was it appropriate for the intended outcome? yes__x___Strength_____Limitation_____Not evident_____Not applicableData collection protocolWere data collection methods appropriate for the intended purpose of the study (e.g., interviews, two focus group meetings, observations, document review)? Data were collected through the conduction of one-time open in depth interviews, guided by a topic list.Was the protocol for conducting the study described thoroughly and in enough detail? YesWere data collection procedures consistently applied to the participants of the study? yesDid the data collector have sufficient qualifications and training? The focus group meetings were performed by principle researcher and psychologist and these meetings increased the preparedness to conduct the interviews.Were data collected long enough to have saturation? N/AWas the protocol ethical and approved by an Institutional Review Board? obtained from the Medical Research EthicsCommittee of the Isala Clinics in ZwolleWhat steps were taken to ensure confidentiality and anonymity of the participants? Assigned a number and data disassociated from patient, provided written informed consentWhat steps were taken to ensure credibility and objectivity during data collection? Tape recorded interview transcribed verbatim___x__Strength_____Limitation_____Not evident_____Not applicableSample Characteristics: sex, education, marital status, A1c level, type insulin used, number of years with DM, number of years of SMBGWere the participants’ characteristics described in enough detail to understand how they contributed to the data? yesWere the participants’ experiences with the phenomenon varied? yes__x___Strength_____Limitation_____Not evident_____Not applicableData analysis used the MAXqda 2007 for analysisWhat steps were taken to ensure that the interview or focus group data were transcribed verbatim? Tape recorded & submitted to 4 respondents to verify summary of interview, all 4 confirmed fair representation.How were data coded? Open, axial, & selective coding under constant comparisonHow were categories and themes constructed? Consensus about the coding, categories and developing theory through researcher triangulation approach__x___Strength_____Limitation_____Not evident_____Not applicableHow were interrelationships established and a theory constructed (e.g., grounded theory approach)? Comparative analysis theoryWhat steps were taken to ensure credibility, dependability, and objectivity during data analysis? 3 different researchers with different backgrounds constant comparison, member and peer review. Researcher triangulation procedure.___x__Strength_____Limitation_____Not evident_____Not applicableFindings Provisional conclusionsand theoretical insights were discussed with a personfrom the Dutch Diabetes Association and a diabetes specialized nurse.Are the themes or theory/presented in an understandable manner? yesAre the findings supported by quotations from the participants to facilitate transferability? yesAre findings presented relative to the intended purpose and each research question? yes_x__Strength_____Limitation_____Not evident_____Not applicableFindingsDid the researcher thoroughly explain their interpretation of the findings? yesWere the explanations logical? YesDid the researchers describe the contribution of their study to understanding the phenomenon? Yes, “Our study not only confirms what has been reported in previous studies, but provides a deeper insight into the perspectives of insulin treated patients with diabetes” (p. 10).Did the researchers discuss how their findings are related to previous studies and theories in their own discipline and, when appropriate, other disciplines? yesDid the researchers thoroughly identify and discuss limitations? Yes, possible selection bias and only for Dutch ethnicity.What are the implications for practice? In daily practice healthcare providers must find a balance between achieving good glycemic control and quality of life for patient.What future research recommendations are made? A new study is started to develop and validate a clinical measurement tool of patients’ perspective of SMBG.__x__Strength_____Limitation_____Not evident_____Not applicableFindingsAre the conclusions in alignment with the intended purpose of the study? yesDo the conclusions logically follow from the findings and interpretation? yes__x__Strength_____Limitation_____Not evident_____Not applicableA quantitative study was also appraised for trustworthiness and validity (see Table 3.2). Our EBP team concluded that this qualitative study is valid and trustworthy. The purpose of the study was clear stated in the research and design section. The methods for sampling, data collection, and statistical analysis were detailed in the text, and were ethical and appropriate. Limitations and biases were defined in the discussion section. The findings relate to the purpose of the research and are logical in relation to the findings. Table 3.2Questions to Establish Trustworthiness of a Quantitative StudyCONTENTQUESTIONSAPPRAISAL(check one box)Author’s names, credentials, affiliations, and conflict of interestDawn Smiley, is assistant professor of medicine at Emory University School of Medicine, Grady Health System. Mary Rhee, MD, 12 years’ experience and practices internal medicine, endocrinology, diabetes and metabolism, and endocrinology and metabolism in Atlanta, Ga. Limin Peng, PhD, fields of study are statistics, probability, control, and optimization at Emory University. Laurian Roediger, BS, degree in neuroscience and behavioral biology at Emory University Patrick Mulligan, BS, medical student at Emory University School of Medicine. Lewis Satterwhite, MD, internist, critical care specialist, pulmonologist. Guilleromo E. Umpierrez, MD, professor of medicine in the division of endocrinology, metabolism at Emory University School of Medicine and chief of diabetes and endocrinology at Grady Memorial Hospital. Patrick Bowen, MD, diabetologist and endocrinologist in Atlanta, Ga. Are the authors’ credentials and educational background appropriate to conduct this type of study? Yes Are the authors affiliated with an educational program, health institution, or practice setting? Yes Do the authors report a conflict of interest? No__X_Strength_____Limitation_____Not evident_____Not applicableFunding source(s)Supported by grants from NIH, American Diabetes Association, and NIH/NCRR Clinical Translational Science AwardDoes the funding source have a vested interest in a beneficial outcome of the study? Yes_____Strength__X__Limitation_____Not evident____ Not applicable PurposeTo determine and evaluate the safety and efficacy of CII in medical-surgical units.Is the intent of the study clearly stated? YesIs the phenomenon being investigated identifiable? YesIs the population identifiable? Yes_X___Strength_____Limitation_____Not evident_____Not applicableResearch designQuantitativeIs the design selected in alignment with the purpose? Yes. Is the design appropriate to reach the stated outcome? YesIs a control or comparison group used when it use strengthens the validity of the outcome? Yes, comparisonAre the researchers blind to the assignment of participants? NoAre the participants blind to their assignment? NoDoes the design limit the number of extraneous variables? No_____Strength_X___Limitation_____Not evident_____Not applicableSample200 consecutive patients receiving CII in general medical-surgical unitsDid the authors describe the population that the sample is intended to represent? Yes Was the sampling frame used appropriate for the purpose of the study? YesWas the inclusion and exclusion criteria clearly described, and was it appropriate for the intended outcome? Yes Was the assignment of participants to treatment and control/comparison groups random or nonrandom, and was the method appropriate? Two groups, non-ICU patients and ICU patientsWas the sample size sufficient to include all applicable variability? Yes_X__Strength_____Limitation_____Not evident_____Not applicableResearch ProtocolCII ProtocolWas the protocol for conducting the study described thoroughly and in enough detail? Yes Was the protocol followed appropriate for the purpose? Yes Did the study continue long enough to have valid outcomes? Yes, Between July 4, 2004 and June 30, 2005 Was the protocol consistently administered? yesDid the researchers take steps to control for extraneous variables? Yes_X___Strength_____Limitation_____Not evident_____Not applicableWas the protocol consistently administered? yesDid the researchers take steps to control for extraneous variables? yesWas the protocol ethical and approved by an Institutional Review Board? No_ ___Strength___X__Limitation_____Not evident_____Not applicableData collectionData collected included demographics medical history, admission diagnoses, inpatient medications, inpatient laboratory values, bedside BG measurements, insulin doses used, nutrition status during CII, length of stay, disposition at discharge, and mortality rate.Were the data collection methods appropriate for the intended purpose of the study? Yes. Were the data collection procedures consistently applied to the participants? YesWas the validity and reliability of the data collection instrument established at a high enough level? Yes. Was the reliability of the data collectors established at a high enough level? Yes_X__Strength_____Limitation_____Not evident_____Not applicableSample200 patients receiving CII while admitted to general medical-surgical unitsWere important demographics of the intervention and control/comparison group similar and, if not, did it impact the results? YesWere treatment and control groups similar at the baseline measurement of the outcome variables and, if not, did this difference impact the results? YesHow were eligible participants accounted for throughout the study? Retrospective chart analysisWas the discontinuance rate comparable between the treatment and control or comparison group? Yes__X__ Strength_____Limitation_____Not evident_____Not applicableData Analysis What did the power analysis indicate? Patients with increased creatinine levels have a risk of hyperglycemia but not hypoglycemia. The analysis also found that younger patients have a higher incident of hyperglycemia than older patients.Were data analyzed using an on-protocol or intention-to-treat analysis, or both? On-protocol analysisIf intention-to-treat analysis was used, what method was used to input missing data? n/aWere the statistical analyses appropriate for the level of data? yesWere the statistical analyses appropriate to test the hypotheses and answer the research question? Yes _____Strength_X___Limitation_____Not evident_____Not applicableFindingsThe study indicated that CII protocol is effective management in a non-critical care setting.Are findings presented relative to each hypothesis and research questions? yesAre findings reported as statistically significant or not significant? SignificantWhen confidence levels are reported, are the upper and lower limits acceptable to implement a change to your practice? YesDo the findings have practical or clinical significance? Clinical significance_____Strength_X___Limitation_____Not evident_____Not applicableFindingsDid the researcher thoroughly explain their interpretation of the findings? YesWere the explanations logical? yesDid the researchers compare their findings to the findings of previous studies and provide a rationale on why they differ? Yes Did the researchers thoroughly identify and discuss the limitations? YesWhat are the implications for practice? CII is safe and effective for management of patients with hyperglycemia in the non-critical care setting.What future research recommendations are made? Future prospective, randomized studies are needed to compare the efficacy and safety of CII protocols to SC insulin protocols in the management of patients with persistent hyperglycemia in the non-ICU setting.__X___Strength_____Limitation_____Not evident_____Not applicableFindingsAre the conclusions in alignment with the intended purpose of the study? YesDo the conclusions logically follow from the findings and interpretation? Yes___X__Strength_____Limitation_____Not evident_____Not applicableCourse of Action(s)Based on the evidence gathered to address the patient problem, the EBP team recommends the hospital adopt a new insulin drip protocol to maintain serum blood glucose levels between 110 and 150 mg/dl. The previous insulin drip protocol to maintain serum blood glucose between 70 and 110 mg/dl is unrealistic for this patient and likely to produce negative outcome of hypoglycemia. Other recommendations of the EBP team include establishing a written protocol for patients on insulin infusion to include direct care nurses make referrals to an endocrinologist consult (if available), diabetic specialist consult (if available), dietician (if available), and outpatient support groups for diabetic patients within 50 mile radius of hospital. Also, the EBP team recommends discharge planning and education to begin on day one of hospitalization from direct care nurses and designated staff, related to diabetes, risk factors, dietary guidelines, lifestyle changes, and patient’s goals and perspectives in relation to self-monitoring of blood glucose levels and quality of life. Discharge planning should also include nurse or designee to make a post-hospital follow-up appointment within one week with patient’s primary care physician.Conclusion Lastly, evaluation of the implemented changes would include the hospital staff monitoring and gathering data on blood glucose levels on patients receiving insulin infusion. Focus will be on hypoglycemic and hyperglycemic episodes as well as any negative outcomes related to any occurrences. Also, the hospital staff will review hospital mortality and readmit rates in this patient population over the next six months to further evaluate effectiveness of newly established protocol. ReferencesAdams, M.P., Holland, N., & Urban, C. (2014). Pharmacology for nurses: Apathophysiologic approach (4th ed.). Boston: Pearson. Bailey, V., Dziura, J., Goldberg, P., Halickman, J., Inzucchi, S., Lee, M., Lee, S., Sherman, R., & Siegel, M. (2004). Implementation of a safe and effective insulin infusion protocol in a medical intensive care unit. Diabetes Care, 27(2), 461-467. doi: 10.2337/diacare 27.2461. Retrieved from: Bilo, H.J.G., Hortensius, J., Jaap, J., Kars, M.C., Kleefstra, N., & Wierenga, W. S. (2012). Perspectives of patients with type 1 or insulin-treated type 2 diabetes on self-monitoring of blood glucose: A qualitative study. BioMed Central Public Health, 12:167. doi: 10.1186/1471-2458-12-167. Retrieved from: Jacobi, J., Bircher, N., Krinsley, J., Agus, M., Braithwaite, S., Deutschman, C., … Schunemann, H. (2012). Guidelines for the use of an insulin infusion for themanagement of hyperglycemia in critically ill patients. Critical Care Medicine,40(12), 3251-3276. DOI: 10.1097/CCM.0b013e3182653269. Retrieved from: Smiley, D., Rhee, M., Limin, P., Roediger, L., Mulligan, P., Satterwhite, L.,…Umpierrez,G. (2010). Safety and efficacy of continuous insulin infusion in noncritical caresettings. Journal of Hospital Medicine: An official publication of the society ofhospital medicine. 5(4), 212-217. doi: 10.1002/jhm.646 Retrieved from: ................
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