Intensive Insulin Therapy in Intensive Care: An Example of the Struggle to Implement Evidence-Based Medicine

A long with improving patients' safety and reducing medical errors, one of the main challenges in medicine is implementing new strategies that have the potential to improve health outcomes. After the process of critically appraising clinical trials has fi nished, and the results of this appraisal are used to guide changes in clinical practice, it is then time to critically appraise the success of implementation. In other words, are physicians really performing the new strategy in its entirety? If they are not, what are the barriers to implementation? Unfortunately, there is no " golden bullet " for successful implementation of new strategies in medicine [1,2]. However, common factors in the failure of implementation have been identifi ed, including environmental factors and factors related to the strategy itself [3]. Critically ill patients without diabetes often develop hyperglycemia. Until recently, it was common practice to treat only marked hyperglycemia in these patients, since hyperglycemia was considered to be an adaptive response to critical illness. But clinical trials have shown that so-called intensive insulin therapy (IIT) aiming at normoglycemia (i.e., blood glucose concentrations [BGC] between 80–110 mg/dl) can signifi cantly decrease mortality and morbidity of patients in the surgical and medical intensive care unit (ICU) [4–7]. We questioned whether IIT truly has become part of standard therapy in ICU patients and, if it is applied, to what extent? We performed a systematic search of the medical literature, in which we focused on surveys and reports on the practice of ITT (see Text S1). We searched for reasons why IIT had not been implemented. We compared factors that hindered implementation of IIT with factors hindering the adoption of other recently introduced strategies, both in ICU medicine and general medicine. Following publication of the fi rst randomized controlled trial of IIT by van den Berghe and colleagues [4], several groups have recommended IIT as the standard of care for those who are critically ill. These groups include the Joint Commission on Accreditation of Healthcare Organization (http:⁄⁄www.jcaho. org), the Institute for Healthcare Improvement (http:⁄⁄www.ihi.org), and the Volunteer Hospital Organization (http:⁄⁄www.vha.com). In addition, IIT is promoted as a part of a care bundle for sepsis by the American Thoracic Society (http:⁄⁄www.thoracic.org) and experts in the fi eld [8]. Also, IIT has become, to some extent, a benchmark for the quality of ICU care [9]. However, over the last few years, a number of commentators have expressed concern …