A Paper-Based, Multiplication-Factor, Intravenous Insulin Protocol
A Paper-Based, Multiplication-Factor, Intravenous Insulin Protocol
Background: Hyperglycemia is common in critically ill patients and is an independent risk factor for in-hospital morbidity and mortality.
Objective: To assess compliance with a paper-based, multiplication-factor, intravenous insulin protocol.
Methods: A retrospective chart review was conducted in a 720-bed urban, academic medical center in Boston, Massachusetts. During a 1-month period, compliance with and the consequent safety and efficacy of the Brigham and Women's Hospital paper-based, multiplication-factor, intravenous insulin protocol was evaluated.
Results: The primary endpoint of protocol compliance, defined as correct adjustment to insulin infusion rate and correct timing of bedside blood glucose concentration (BBGC) checks ±10 minutes of prespecified BBGC check according to the Brigham and Women's Hospital Intravenous Insulin Protocol (BHIP), was 47.2%. Seventy-two patients met inclusion criteria. Appropriate adjustment of infusion rates occurred 68.2% (1206/1768) of the time. Compliance with the timing of BBGC checks was found to be the majority of protocol violations. BBGCs were monitored ±5 minutes of indicated time per the protocol 26.2% (463/1768) of the time. Blood glucose concentration checks within extended timing of ±10 minutes of indicated time per the protocol occurred 793 (44.8%) times. Blood glucose concentration monitoring took place greater than 20 minutes past indicated time 450 (25.5%) times. In 1768 measurements, blood glucose concentrations between 40 and 60 mg/dL occurred 23 (1.3%) times in 12 (16.7%) patients. Blood glucose concentrations 40 mg/dL or less were detected 3 (0.17%) times in 2 (2.7%) patients. None of these hypoglycemic events led to documented complications.
Conclusions: Overall, a rather low level of compliance with a paper-based, multiplication-factor, intravenous insulin protocol was observed, which warrants further investigation. Compliance rates in this evaluation were found to be similar to the rates observed in previously evaluated fixed-dose intravenous insulin protocols. Protocol noncompliance may be associated with hypo- and hyperglycemia.
Hyperglycemia is common in critically ill patients and is an independent risk factor for in-hospital morbidity and mortality. Glycemic control has been shown to improve outcomes in numerous studies. Recently, the American Diabetes Association (ADA) and American Association of Clinical Endocrinologists (AACE) recommended a glucose range of 140–180 mg/dL in the majority of critically ill patients. The American College of Endocrinology (ACE) specifically recommends target blood glucose levels of 80–110 mg/dL. Currently, there is no standard protocol that is endorsed by the ADA, AACE, or ACE that would meet their target blood glucose levels; however, the ADA/AACE/ACE guidelines have described the crucial elements of the optimal protocol including: predefined adjustments for previous and current glucose levels, the rate of change in glucose, the insulin infusion rate, and the need for frequent glucose checks.
The optimal glucose target in the intensive care unit (ICU) is a controversial subject. However, regardless of what the numeric target may be for an institution (eg, 80–140 mg/dL, <150 mg/dL), an intravenous insulin protocol may be used to attain that target. Assessment of protocol compliance becomes increasingly important as the safety of tight glycemic control has come into question in recent publications. Without knowledge of protocol compliance, evaluations of safety and efficacy are difficult to interpret. Therefore, even though institutions may have different target ranges, protocols, and/or clinical practice, assessing compliance with intravenous insulin protocols (timing of glucose checks and infusion rate adjustments) is warranted and becomes a valuable quality assessment marker. Several protocols have been evaluated for safety and efficacy but there have been only a few published evaluations of compliance with intravenous insulin protocols.
Brigham and Women's Hospital implemented a paper-based, multiplication-factor intravenous insulin protocol in 2006. The Brigham and Women's Hospital Intravenous Insulin Protocol (BHIP) has previously been evaluated for its efficacy and safety (internal data); however, the role of compliance has not been addressed. To our knowledge, evaluation of compliance with a paper-based, multiplication-factor, intravenous insulin protocol has not been described in the literature, which is important due to the complexity associated with the multiplication-factor protocols. The purpose of this evaluation was to assess compliance with a paper-based, multiplication-factor, intravenous insulin protocol. A secondary objective was to assess the association of compliance with the safety and efficacy of the protocol.
Abstract and Introduction
Abstract
Background: Hyperglycemia is common in critically ill patients and is an independent risk factor for in-hospital morbidity and mortality.
Objective: To assess compliance with a paper-based, multiplication-factor, intravenous insulin protocol.
Methods: A retrospective chart review was conducted in a 720-bed urban, academic medical center in Boston, Massachusetts. During a 1-month period, compliance with and the consequent safety and efficacy of the Brigham and Women's Hospital paper-based, multiplication-factor, intravenous insulin protocol was evaluated.
Results: The primary endpoint of protocol compliance, defined as correct adjustment to insulin infusion rate and correct timing of bedside blood glucose concentration (BBGC) checks ±10 minutes of prespecified BBGC check according to the Brigham and Women's Hospital Intravenous Insulin Protocol (BHIP), was 47.2%. Seventy-two patients met inclusion criteria. Appropriate adjustment of infusion rates occurred 68.2% (1206/1768) of the time. Compliance with the timing of BBGC checks was found to be the majority of protocol violations. BBGCs were monitored ±5 minutes of indicated time per the protocol 26.2% (463/1768) of the time. Blood glucose concentration checks within extended timing of ±10 minutes of indicated time per the protocol occurred 793 (44.8%) times. Blood glucose concentration monitoring took place greater than 20 minutes past indicated time 450 (25.5%) times. In 1768 measurements, blood glucose concentrations between 40 and 60 mg/dL occurred 23 (1.3%) times in 12 (16.7%) patients. Blood glucose concentrations 40 mg/dL or less were detected 3 (0.17%) times in 2 (2.7%) patients. None of these hypoglycemic events led to documented complications.
Conclusions: Overall, a rather low level of compliance with a paper-based, multiplication-factor, intravenous insulin protocol was observed, which warrants further investigation. Compliance rates in this evaluation were found to be similar to the rates observed in previously evaluated fixed-dose intravenous insulin protocols. Protocol noncompliance may be associated with hypo- and hyperglycemia.
Introduction
Hyperglycemia is common in critically ill patients and is an independent risk factor for in-hospital morbidity and mortality. Glycemic control has been shown to improve outcomes in numerous studies. Recently, the American Diabetes Association (ADA) and American Association of Clinical Endocrinologists (AACE) recommended a glucose range of 140–180 mg/dL in the majority of critically ill patients. The American College of Endocrinology (ACE) specifically recommends target blood glucose levels of 80–110 mg/dL. Currently, there is no standard protocol that is endorsed by the ADA, AACE, or ACE that would meet their target blood glucose levels; however, the ADA/AACE/ACE guidelines have described the crucial elements of the optimal protocol including: predefined adjustments for previous and current glucose levels, the rate of change in glucose, the insulin infusion rate, and the need for frequent glucose checks.
The optimal glucose target in the intensive care unit (ICU) is a controversial subject. However, regardless of what the numeric target may be for an institution (eg, 80–140 mg/dL, <150 mg/dL), an intravenous insulin protocol may be used to attain that target. Assessment of protocol compliance becomes increasingly important as the safety of tight glycemic control has come into question in recent publications. Without knowledge of protocol compliance, evaluations of safety and efficacy are difficult to interpret. Therefore, even though institutions may have different target ranges, protocols, and/or clinical practice, assessing compliance with intravenous insulin protocols (timing of glucose checks and infusion rate adjustments) is warranted and becomes a valuable quality assessment marker. Several protocols have been evaluated for safety and efficacy but there have been only a few published evaluations of compliance with intravenous insulin protocols.
Brigham and Women's Hospital implemented a paper-based, multiplication-factor intravenous insulin protocol in 2006. The Brigham and Women's Hospital Intravenous Insulin Protocol (BHIP) has previously been evaluated for its efficacy and safety (internal data); however, the role of compliance has not been addressed. To our knowledge, evaluation of compliance with a paper-based, multiplication-factor, intravenous insulin protocol has not been described in the literature, which is important due to the complexity associated with the multiplication-factor protocols. The purpose of this evaluation was to assess compliance with a paper-based, multiplication-factor, intravenous insulin protocol. A secondary objective was to assess the association of compliance with the safety and efficacy of the protocol.
Source...