insulininfusion icu

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Insulin Infusion Protocol in theInsulin Infusion Protocol in theICUICU

Changing CareChanging CultureChanging CareChanging Culture

By: Holly Ann Roush, RN, BSN, NurseBy: Holly Ann Roush, RN, BSN, NurseClinician level IVClinician level IV


2/22

In the pastIn the past

What patients were placed on insulin infusions?What patients were placed on insulin infusions?

What did management of the patient entail?What did management of the patient entail?

What nursing management was required?What nursing management was required?

What were the positive points of the past managementWhat were the positive points of the past management

model?model?

What were the negative points of the model?What were the negative points of the model?


3/22

What patients were placed onWhat patients were placed on

insulin infusions?insulin infusions? Extremely sick and physically stressedExtremely sick and physically stressed

patients.patients.

No medical/surgical floor patients.No medical/surgical floor patients.

Patients with glucoses above 200Patients with glucoses above 200--300 after300 after

failed attempts to lower glucose withfailed attempts to lower glucose with

sliding scale insulin therapy.sliding scale insulin therapy.


4/22


5/22

What nursing management was required?What nursing management was required?

Example: post operative open heartExample: post operative open heartsurgery.surgery.

Serum would be sent for glucose and otherSerum would be sent for glucose and otherlabs.labs.

Elevate serum glucose would be reportedElevate serum glucose would be reported

to MD.to MD. Intial treatment may be sliding scaleIntial treatment may be sliding scale

insulin by subcutaneous injection.insulin by subcutaneous injection.


6/22

Nursing managementNursing management Serum glucose rechecked.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.with or without insulin bolus.

Serum glucose levels then checked everySerum glucose levels then checked every

hour.hour. Adjustments made till glucose levelAdjustments made till glucose level

lowered to an acceptable level.lowered to an acceptable level.


7/22

Nursing Management continuedNursing Management continued Serum glucose and reporting to MD usuallySerum glucose and reporting to MD usually

continued hourly for duration of insulincontinued hourly for duration of insulin

infusion therapy.infusion therapy.


8/22

Positive points of the pastPositive points of the past

management model.management model. Work load decreased due to lower numberWork load decreased due to lower number

of patients on insulin infusions.of patients on insulin infusions.

Management is ordered patient specific.Management is ordered patient specific.


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Negative points of the pastNegative points of the past

model.model.

Few patients with adequate glucoseFew patients with adequate glucose

control.control.

Care is very time consuming inCare is very time consuming in

correspondence with MD.correspondence with MD.

Blood loss/draw to do serum glucoses isBlood loss/draw to do serum glucoses is

high with sampling of 3mls every hour.high with sampling of 3mls every hour.


10/22

More negative points!More negative points!

Excessive, but necessary time for lab to processExcessive, but necessary time for lab to process

and post glucose.and post glucose.

patient is always receiving therapy for past glucosepatient is always receiving therapy for past glucoselevel.level.

Unable to achieve optimal glucose control in aUnable to achieve optimal glucose control in a

short amount of time.short amount of time.

It is difficult to treat multiple patients in the ICUIt is difficult to treat multiple patients in the ICU

with insulin infusions.with insulin infusions.

Impossible for Floor RNImpossible for Floor RN


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Is there a need for change?Is there a need for change?

Maintaining blood glucose between 80Maintaining blood glucose between 80--110mg/dl reduced110mg/dl reduced

ICU mortality by 42%. (reference #3)ICU mortality by 42%. (reference #3)

Even moderately elevated glucose levels in the criticallyEven moderately elevated glucose levels in the criticallyill patient can cause cytopathic hypoxia. (reference # 2)ill patient can cause cytopathic hypoxia. (reference # 2)

Accelerated toxicity of hyperglycemia and lack of insulinAccelerated toxicity of hyperglycemia and lack of insulin

effect is greatly associated to increase in multiple systemeffect is greatly associated to increase in multiple system

organ failure. (reference #2)organ failure. (reference #2)

Therepeutic control of glucose levels (80Therepeutic control of glucose levels (80--120) reduces120) reduces

morbidity, mortality, and length of ICU stay. (#4)morbidity, mortality, and length of ICU stay. (#4)


12/22

Present Care of thePresent Care of the

Hyperglycemia.Hyperglycemia. What patients are placed on insulin infusions?What patients are placed on insulin infusions?

What does management of the patient entail?What does management of the patient entail?

What nursing management is required?What nursing management is required?

What are the positive points of treatment with an InsulinWhat are the positive points of treatment with an Insulin

infusion protocol?infusion protocol?

What are the negative points of treatment with an InsulinWhat are the negative points of treatment with an Insulin

infusion protocol?infusion protocol?


13/22

What patients are placed onWhat patients are placed on

insulin infusions?insulin infusions? Any adult inpatient can receive therapeuticAny adult inpatient can receive therapeutic

glucose control via an insulin infusion.glucose control via an insulin infusion.

This includes medical and surgical floorThis includes medical and surgical floor

patients, and patients on any admittingpatients, and patients on any admitting

service.service.


14/22

What does management of the patient on anWhat does management of the patient on an

insulin infusion entail?insulin infusion entail?

MD orders the Insulin Infusion Protocol due toMD orders the Insulin Infusion Protocol due to

elevated glucose level or diabetic history.elevated glucose level or diabetic history.

Glucose control and insulin therapyGlucose control and insulin therapycollaboratively reviewed on daily bedside rounds.collaboratively reviewed on daily bedside rounds.

Nurse required to notify MD only if problems withNurse required to notify MD only if problems with

glucose control due to change in clinical picture.glucose control due to change in clinical picture.


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What nursing management is required?What nursing management is required?

Nursing clarifies/obtains order for insulinNursing clarifies/obtains order for insulin

infusion.infusion.

Nurse checks blood glucose using bedsideNurse checks blood glucose using bedsideglucose meter.glucose meter.

Insulin infusion is administered via infusionInsulin infusion is administered via infusion

pump after being double checked by another RN.pump after being double checked by another RN.

Bedside glucose checks are done hourly andBedside glucose checks are done hourly and

infusion adjusted according to protocol.infusion adjusted according to protocol.


16/22

What are the positive points of treatment with anWhat are the positive points of treatment with an

Insulin infusion protocol?Insulin infusion protocol?

Less time spent on care of single patient with anLess time spent on care of single patient with aninsulin infusion.insulin infusion.

Can treat multiple patients effectively forCan treat multiple patients effectively forhyperglycemia.hyperglycemia.

Glucose control occurs more quickly.Glucose control occurs more quickly.

Can safely treat patient to keep glucose level 80Can safely treat patient to keep glucose level 80--

100mg/dl.100mg/dl. Infusion dose changes are done earlier in theInfusion dose changes are done earlier in the

point of care.point of care.


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More positive pointsMore positive points.. Cost savings to patient, hospital, andCost savings to patient, hospital, and

insurance company.insurance company.

Cheaper to do Glucometer checks than serumCheaper to do Glucometer checks than serumlabs.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, orLess sequela of critical illness, injury, orintervention.intervention.


18/22

More positive points!More positive points! Allows nursing to be more autonomous.Allows nursing to be more autonomous.

More nursing hours spent in actual patientMore nursing hours spent in actual patientcare.care.

Glucose control can occur safely for aGlucose control can occur safely for a

lower glucose level.lower glucose level.

Less blood loss for the patient.Less blood loss for the patient.


19/22

Facilitators to acceptance of theFacilitators to acceptance of the

Insulin Infusion Protocol.Insulin Infusion Protocol. Move towards evidence based practice.Move towards evidence based practice.

Piloted on a specific patient care population.Piloted on a specific patient care population.

Extensive educational inservicing onExtensive educational inservicing on

administration of insulin infusions as peradministration of insulin infusions as per

protocol.protocol.

Introduction and inIntroduction and in--servicing of use of bedsideservicing of use of bedsideglucose meters in the bedside setting.glucose meters in the bedside setting.


20/22

Barriers to acceptance of theBarriers to acceptance of the

Insulin Infusion ProtocolInsulin Infusion Protocol.. Change is always resistedChange is always resisted

Multiple modifications to the protocolMultiple modifications to the protocol

Increase workload on nursing staff with theIncrease workload on nursing staff with the

added responsibilities.added responsibilities.


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ConclusionsConclusions The term hyperglycemic patient needed to beThe term hyperglycemic patient needed to be

redefined in the inpatient clinical setting.redefined in the inpatient clinical setting.

Past treatment of hyperglycemic patients withPast treatment of hyperglycemic patients withsliding scale insulin and patient specific orderedsliding scale insulin and patient specific ordered

insulin infusions was inadequate.insulin infusions was inadequate.

New methods of treating hyperglycemia fromNew methods of treating hyperglycemia from

hospital admission to discharge need to behospital admission to discharge need to be

developed and explored.developed and explored.


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ReferencesReferences

Abourizk, Nicholas N., Vora, Chaula K., Verma, Parveen.Abourizk, Nicholas N., Vora, Chaula K., Verma, Parveen. Inpatient diabetology:Inpatient diabetology:

The new frontier.The new frontier. Journal of General Internal Medicine. May 2004, (466Journal of General Internal Medicine. May 2004, (466--471).471).

Berghe, Greet Van den.Berghe, Greet Van den. How does blood glucose control with insulin save livesHow does blood glucose control with insulin save livesin intensive care?.in intensive care?. The Journal of Clinical Investigation; November 2004 114, 9The Journal of Clinical Investigation; November 2004 114, 9

(1187(1187--1195) .1195) .

Goldberg, Philip A., Siegel, Mark D., Sherwin, Robert S., Halickman, Joshua I.; etGoldberg, Philip A., Siegel, Mark D., Sherwin, Robert S., Halickman, Joshua I.; et

al.al. Implementation of a safe and effective insulin infusion protocol in aImplementation of a safe and effective insulin infusion protocol in a

medical intensive care unit.medical intensive care unit. Diabetes Care: Feb. 2004; 27, 2 (461Diabetes Care: Feb. 2004; 27, 2 (461--467).467).

Vora, Amit C., Tipufaiz, Saleem M., Polomana, Rosemary C., Eddinger, Victoria L.,Vora, Amit C., Tipufaiz, Saleem M., Polomana, Rosemary C., Eddinger, Victoria L.,

Hollenbeak, Christopher S., Girdharry, Dexter T., Joshi, Renu, Martin, Donal,Hollenbeak, Christopher S., Girdharry, Dexter T., Joshi, Renu, Martin, Donal,

Gabbay, Robert A.Gabbay, Robert A. Improved perioperative glycemic control by continuousImproved perioperative glycemic control by continuous

insulin infusion under supervision of an endocrinologist does not increaseinsulin infusion under supervision of an endocrinologist does not increase

costs in patients with diabetes.costs in patients with diabetes. Endocrine Practice; March/April 2004.Endocrine Practice; March/April 2004.

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