Insulin Infusion Protocol in the ICU

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Insulin Infusion Protocol in the ICU

• Changing CareChanging Culture
• By Holly Ann Roush, RN, BSN, Nurse Clinician
  level IV

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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?

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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.

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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.

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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.

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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.

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Nursing Management continued

• Serum glucose and reporting to MD usually
  continued hourly for duration of insulin infusion
  therapy.

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Positive points of the past management model.

• Work load decreased due to lower number of
  patients on insulin infusions.
• Management is ordered patient specific.

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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.

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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

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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)

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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?

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.