Insulin Infusion Protocol in the ICU Changing Care…Changing Culture By: Holly Ann Roush, RN, BSN, Nurse Clinician level IV

In the past… In the past… b What patients were placed on insulin infusions? b What did management of the patient entail? b What nursing management was required? b What were the positive points of the past management model? b What were the negative points of the model?

What patients were placed on insulin infusions? b Extremely sick and physically stressed patients. b No medical/surgical floor patients. b Patients with glucoses above after failed attempts to lower glucose with sliding scale insulin therapy.

What did management of the patient entail? b MD would order glucose levels to be check at a designated time interval. b Bedside nurse could only drawing and send a serum glucose. b Results were available approximately minutes after received by the lab.

What nursing management was required? b Example: post operative open heart surgery. b Serum would be sent for glucose and other labs. b Elevate serum glucose would be reported to MD. b Intial treatment may be sliding scale insulin by subcutaneous injection.

Nursing management b Serum glucose rechecked. Elevated result reported to MD.Elevated result reported to MD. Insulin infusion ordered and intiated.Insulin infusion ordered and intiated. – with or without insulin bolus. b Serum glucose levels then checked every hour. b Adjustments made till glucose level lowered to an acceptable level.

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

Positive points of the past management model. b Work load decreased due to lower number of patients on insulin infusions. b Management is ordered patient specific.

Negative points of the past model. b Few patients with adequate glucose control. b Care is very time consuming in correspondence with MD. b Blood loss/draw to do serum glucoses is high with sampling of 3mls every hour.

More negative points! b Excessive, but necessary time for lab to process and post glucose. patient is always receiving therapy for past glucose level. patient is always receiving therapy for past glucose level. b Unable to achieve optimal glucose control in a short amount of time. b It is difficult to treat multiple patients in the ICU with insulin infusions. Impossible for Floor RNImpossible for Floor RN

Is there a need for change? b Maintaining blood glucose between mg/dl reduced ICU mortality by 42%. (reference #3) b Even moderately elevated glucose levels in the critically ill patient can cause cytopathic hypoxia. (reference # 2) b Accelerated toxicity of hyperglycemia and lack of insulin effect is greatly associated to increase in multiple system organ failure. (reference #2) b Therepeutic control of glucose levels (80-120) reduces morbidity, mortality, and length of ICU stay. (#4)

Present Care of the Hyperglycemia. b What patients are placed on insulin infusions? b What does management of the patient entail? b What nursing management is required? b What are the positive points of treatment with an Insulin infusion protocol? b What are the negative points of treatment with an Insulin infusion protocol?

What patients are placed on insulin infusions? b 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.This includes medical and surgical floor patients, and patients on any admitting service.

What does management of the patient on an insulin infusion entail? b MD orders the Insulin Infusion Protocol due to elevated glucose level or diabetic history. b Glucose control and insulin therapy collaboratively reviewed on daily bedside rounds. b Nurse required to notify MD only if problems with glucose control due to change in clinical picture.

What nursing management is required? b Nursing clarifies/obtains order for insulin infusion. b Nurse checks blood glucose using bedside glucose meter. b Insulin infusion is administered via infusion pump after being double checked by another RN. b Bedside glucose checks are done hourly and infusion adjusted according to protocol.

What are the positive points of treatment with an Insulin infusion protocol? b Less time spent on care of single patient with an insulin infusion. b Can treat multiple patients effectively for hyperglycemia. b Glucose control occurs more quickly. b Can safely treat patient to keep glucose level mg/dl. b Infusion dose changes are done earlier in the point of care.

More positive points. b Cost savings to patient, hospital, and insurance company. Cheaper to do Glucometer checks than serum labs.Cheaper to do Glucometer checks than serum labs. Less days of stay in the ICULess days of stay in the ICU Less days of stay in the hospitalLess days of stay in the hospital Lower rates of nosocomial infections.Lower rates of nosocomial infections. Less sequela of critical illness, injury, or intervention.Less sequela of critical illness, injury, or intervention.

More positive points! b Allows nursing to be more autonomous. b More nursing hours spent in actual patient care. b Glucose control can occur safely for a lower glucose level. b Less blood loss for the patient.

Facilitators to acceptance of the Insulin Infusion Protocol. b Move towards evidence based practice. b Piloted on a specific patient care population. b Extensive educational inservicing on administration of insulin infusions as per protocol. b Introduction and in-servicing of use of bedside glucose meters in the bedside setting.

Barriers to acceptance of the Insulin Infusion Protocol. b Change is always resisted b Multiple modifications to the protocol b Increase workload on nursing staff with the added responsibilities.

Conclusions b The term hyperglycemic patient needed to be redefined in the inpatient clinical setting. b Past treatment of hyperglycemic patients with sliding scale insulin and patient specific ordered insulin infusions was inadequate. b New methods of treating hyperglycemia from hospital admission to discharge need to be developed and explored.

References b Abourizk, Nicholas N., Vora, Chaula K., Verma, Parveen. Inpatient diabetology: The new frontier. Journal of General Internal Medicine. May 2004, ( ). b Berghe, Greet Van den. How does blood glucose control with insulin save lives in intensive care?. The Journal of Clinical Investigation; November , 9 ( ). b 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 ( ). b 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.