Insulin Infusion Protocol in the

ICU

Changing Care…Changing Culture

By: Holly Ann Roush, RN, BSN, Nurse
Clinician level IV
 In the past…
❂ What patients were placed on insulin infusions?
❂ What did management of the patient entail?
❂ What nursing management was required?
❂ What were the positive points of the past management
model?
❂ What were the negative points of the model?
What patients were placed on
insulin infusions?
❂ Extremely sick and physically stressed
patients.
❂ No medical/surgical floor patients.
❂ Patients with glucoses above 200-300 after
failed attempts to lower glucose with
sliding scale insulin therapy.
What did management of the patient entail?

❂ MD would order glucose levels to be check

at a designated time interval.
❂ Bedside nurse could only drawing and
send a serum glucose.
❂ Results were available approximately 45-
60minutes after received by the lab.
What nursing management was required?

❂ Example: post operative open heart surgery.

❂ Serum would be sent for glucose and other
labs.
❂ Elevate serum glucose would be reported to
MD.
❂ Intial treatment may be sliding scale insulin by
subcutaneous injection.
Nursing management
❂ Serum glucose rechecked.
• Elevated result reported to MD.
• Insulin infusion ordered and intiated.
– with or without insulin bolus.
❂ Serum glucose levels then checked every
hour.
❂ Adjustments made till glucose level
lowered to an acceptable level.
Nursing Management continued
❂ Serum glucose and reporting to MD usually
continued hourly for duration of insulin
infusion therapy.
Positive points of the past
management model.
❂ Work load decreased due to lower number
of patients on insulin infusions.
❂ Management is ordered patient specific.
Negative points of the past
model.

❂ Few patients with adequate glucose

control.
❂ Care is very time consuming in
correspondence with MD.
❂ Blood loss/draw to do serum glucoses is
high with sampling of 3mls every hour.
More negative points!
❂ Excessive, but necessary time for lab to process
and post glucose.
• patient is always receiving therapy for past glucose
level.
❂ Unable to achieve optimal glucose control in a
short amount of time.
❂ It is difficult to treat multiple patients in the ICU
with insulin infusions.
• Impossible for Floor RN
Is there a need for change?

❂ Maintaining blood glucose between 80-110mg/dl reduced

ICU mortality by 42%. (reference #3)
❂ Even moderately elevated glucose levels in the critically
ill patient can cause cytopathic hypoxia. (reference # 2)
❂ Accelerated toxicity of hyperglycemia and lack of insulin
effect is greatly associated to increase in multiple system
organ failure. (reference #2)
❂ Therepeutic control of glucose levels (80-120) reduces
morbidity, mortality, and length of ICU stay. (#4)
Present Care of the
Hyperglycemia.
❂ What patients are placed on insulin infusions?
❂ What does management of the patient entail?
❂ What nursing management is required?
❂ What are the positive points of treatment with an Insulin
infusion protocol?
❂ What are the negative points of treatment with an Insulin
infusion protocol?
What patients are placed on
insulin infusions?
❂ Any adult inpatient can receive therapeutic
glucose control via an insulin infusion.
• This includes medical and surgical floor
patients, and patients on any admitting
service.
What does management of the patient on an
insulin infusion entail?

❂ MD orders the Insulin Infusion Protocol due to

elevated glucose level or diabetic history.
❂ Glucose control and insulin therapy
collaboratively reviewed on daily bedside rounds.
❂ Nurse required to notify MD only if problems with
glucose control due to change in clinical picture.
What nursing management is required?

❂ Nursing clarifies/obtains order for insulin

infusion.
❂ Nurse checks blood glucose using bedside
glucose meter.
❂ Insulin infusion is administered via infusion
pump after being double checked by another RN.
❂ Bedside glucose checks are done hourly and
infusion adjusted according to protocol.
What are the positive points of treatment with an
Insulin infusion protocol?

❂ Less time spent on care of single patient with an

insulin infusion.
❂ Can treat multiple patients effectively for
hyperglycemia.
❂ Glucose control occurs more quickly.
❂ Can safely treat patient to keep glucose level 80-
100mg/dl.
❂ Infusion dose changes are done earlier in the point
of care.
More positive points.
❂ Cost savings to patient, hospital, and
insurance company.
• Cheaper to do Glucometer checks than serum
labs.
• Less days of stay in the ICU
• Less days of stay in the hospital
• Lower rates of nosocomial infections.
• Less sequela of critical illness, injury, or
intervention.
More positive points!
❂ Allows nursing to be more autonomous.
❂ More nursing hours spent in actual patient
care.
❂ Glucose control can occur safely for a
lower glucose level.
❂ Less blood loss for the patient.
Facilitators to acceptance of the
Insulin Infusion Protocol.
❂ Move towards evidence based practice.
❂ Piloted on a specific patient care population.
❂ Extensive educational inservicing on
administration of insulin infusions as per
protocol.
❂ Introduction and in-servicing of use of bedside
glucose meters in the bedside setting.
Barriers to acceptance of the
Insulin Infusion Protocol.
❂ Change is always resisted
❂ Multiple modifications to the protocol
❂ Increase workload on nursing staff with the
added responsibilities.
Conclusions
❂ The term “hyperglycemic patient” needed to be
redefined in the inpatient clinical setting.
❂ Past treatment of hyperglycemic patients with
sliding scale insulin and patient specific ordered
insulin infusions was inadequate.
❂ New methods of treating hyperglycemia from
hospital admission to discharge need to be
developed and explored.
References

❂ Abourizk, Nicholas N., Vora, Chaula K., Verma, Parveen. Inpatient diabetology:
The new frontier. Journal of General Internal Medicine. May 2004, (466-471).
❂ Berghe, Greet Van den. How does blood glucose control with insulin save lives
in intensive care?. The Journal of Clinical Investigation; November 2004 114, 9
(1187-1195) .
❂ Goldberg, Philip A., Siegel, Mark D., Sherwin, Robert S., Halickman, Joshua I.; et al.
Implementation of a safe and effective insulin infusion protocol in a medical
intensive care unit. Diabetes Care: Feb. 2004; 27, 2 (461-467).
❂ Vora, Amit C., Tipufaiz, Saleem M., Polomana, Rosemary C., Eddinger, Victoria L.,
Hollenbeak, Christopher S., Girdharry, Dexter T., Joshi, Renu, Martin, Donal,
Gabbay, Robert A. Improved perioperative glycemic control by continuous
insulin infusion under supervision of an endocrinologist does not increase
costs in patients with diabetes. Endocrine Practice; March/April 2004.