الفهرس 
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Abstract
Hyperglycemia is common among critically ill patients in the ICUs with and without history of diabetes, it may be a marker of severe, acute illness or may worsen the outcomes across various inpatient subpopulations. It is contributing to inflammation, oxidative stress, poor immune function, and endothelial dysfunction. Therefore, implementation of the intensive insulin therapy through ensured effective and safe protocols has been proposed as the treatment of choice for hyperglycemia in critically ill hospitalized patients.
Despite conflicting evidence regarding safety and effectiveness, the IIT has been recommended as the standard of care for critically ill patients. The ADA, AACE, and other professional organizations has considered implementation of the IIT with specific modification in glucose target. The Nurses led insulin protocol has several potential advantages including continuous availability of the nurses at the patients’ bedside; the nurses are more familiar than other health care providers with the patients’ characteristics and responses. Moreover, the nurses in the ICUs have experiences and receive training in titrating doses of the infused medications, and able than other providers to respond proactively to a patient’s rapidly changing needs.
Thus, appropriate treatment and monitoring of the blood glucose of the critically ill patient is crucial. This approach increases nurses’ autonomy; a concept that has been associated with increasing their perceptions of improved quality of care and job satisfaction. Therefore, this study was carried out to determine the effect of the nurses led insulin protocol on glycemic control among hyperglycemic mechanically ventilated patients.
Materials and method:
This quasi experimental study was carried out throughout eight months on sixty adult hyperglycemic mechanically ventilated patients from May 2016 to Dec 2016, in three ICUs; casualty unit (unit I), general ICU (unit III), in addition to unit II, at AMUH. The involved patients assigned randomly one by one into two groups. group A the control group who were managed by the routine management of the ICUs, and group B; the intervention group, who were managed by the nurse led insulin protocol. Patients who were weaned from the mechanical ventilation in less than three days and patients who underwent hemodynamic instability were excluded from the study.
Hyperglycemic mechanically ventilated patient assessment record was developed by the researcher, it consists of two parts; the part I “hyperglycemic mechanically ventilated patients’ characteristics” was used to collect demographic data and the clinical characteristics of the studied HGMVPs which include past history, present history, and the therapeutic interventions. While, part II “blood glucose monitoring record” was used to record patients’ random blood glucose measurements during the period of the study. It consists of two sections; the first section was used for the blood glucose measurements and the second two was used to document the short term outcomes.
For the control group (group A) who were managed by the routine management of the ICUs; part ΙΙ of the tool was used to document the value of the blood glucose level in each time it was measured according to the routine followed intervention
For the intervention group (group B) who were managed by the nurse led insulin protocol; the blood glucose level was monitored by a calibrated point of care device (ACCU check active; Germany) and the values documented in the part ΙΙ of the tool. In the first eight hours of protocol implementation, the blood glucose of the patients in intervention group were measured hourly, then in the next eight hours were measured each two hours, and then each four hours until the end of the study, unless unusual modification (s) were required. Concomitantly, the insulin doses were adjusted and moved up and down according the nurse led insulin algorithm.
Form the findings of the current study, it can be concluded that:
• The hyperglycemic mechanically ventilated patients who were managed by the nurse led insulin protocol experienced lower mean blood glucose level than those who were managed by routine management of the ICUs.
• The hyperglycemic mechanically ventilated patients who were managed by the nurse led insulin protocol experienced lower glucose variability than those who were managed by routine management of the ICUs.
• This study didn’t revealed any episodes of hypoglycemia during the period of the study, which mean that the nurse led insulin protocol was safe to be implemented among critically ill patients for control blood glucose.
Based on the present study findings, the following recommendations are suggested:
• Apply the nurse led insulin protocol to achieve a normal blood glucose level for critically ill patients.
• Encourage collaboration between critical care nurses, physicians, dietitian and other ICU members in the implementation of nurse led insulin protocol.
• Include nurse led protocols in the new trends courses for under and post graduate student
• Develop in-service education and training programs to increase critical care nurse’s awareness regarding nurse led insulin protocol for glycemic control.
• Construct multi-disciplinary team to implement nurse led insulin protocol.
• Set policies to support the CCNs in the implementation of the nurse led insulin protocol in the ICUs.
• Include nurse led insulin protocol as a part nursing flow chart.
• Consider further researchers about efficacy and safety of nurse led insulin protocol.
• Replicate this study on a larger sample size, in multicenter and for longer duration for generalization of the results.