Optimizing Hospital Use of Intravenous Insulin Therapy: Improved Management of Hyperglycemia and Error Reduction With a New Nomogram |
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| Affiliation: | 1. Division of Endocrinology, Metabolism, and Nutrition, Durham, North Carolina.;2. Duke University Medical Center, Durham, North Carolina.;3. Department of Medicine, Duke University Medical Center, Durham, North Carolina;1. Universiti Malaysia Pahang, Faculty of Mechanical Engineering, 26600 Pekan, Pahang, Malaysia;2. Universiti Sains Malaysia, Advanced Medical and Dental Institute, 13200 Bertam, Kepala Batas, Penang, Malaysia;3. Universiti Tenaga Nasional, College of Engineering, Putrajaya Campus, 43000 Kajang, Selangor, Malaysia;4. International Islamic University Malaysia, Kuliyyah of Medicine, 25200 Kuantan, Pahang, Malaysia;5. University of Canterbury, Department of Mechanical Engineering, Private Bag 4800, Christchurch 8041, New Zealand;1. Division of Critical, Department of Medicine; Stamford Hospital and Columbia University College of Physicians and Surgeons; Stamford, Connecticut;2. Department of Critical Care, Erasme University Hospital, Universite Libre de Bruxelles, Brussels, Belgium;3. University of Washington School of Medicine, Department of Medicine, Division of Metabolism, Endocrinology, & Nutrition, Seattle, Washington.;1. Department of Cardio-Anaesthesiology, University Hospital Virgen de la Victoria, Málaga, Spain;2. Instituto de Investigaciones Biomédicas de Málaga (IBIMA), University Hospital Virgen de la Victoria, Málaga, Spain;3. CIBER Unidad de Gestión Clínica de Endocrinología y Nutrición, Málaga, Spain;4. Department of Anesthesia, Hospital Universitario Sanitas La Moraleja, Spain;5. Department of Anesthesia, Hospital Universitario La Paz, Madrid. Spain;6. CIBER Fisiología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Málaga, Spain;7. Unidad de Gestión Clínica de Endocrinología y Nutrición, Spain;1. GIGA–Cardiovascular Sciences, Institut de Physique, Université de Liege, Institut de Physics, Allée du 6 Août, 17 (Bât B5), B4000 Liege, Liege, Belgium;2. Department of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Private Bag 4800, Christchurch 8054, New Zealand;3. Department of Intensive Care, Erasme University Hospital, 808 route de Lennik, B1070 Brussels, Belgium;4. School of Medicine, University of Otago Christchurch, Christchurch 8054, New Zealand;5. Department of Intensive Care, Christchurch Hospital, Christchurch 8054, New Zealand |
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| Abstract: | ObjectiveTo assess the efficacy and safety of intravenous (IV) insulin administration with use of our institution’s old protocol (pre-nomogram phase) as compared with our new insulin nomogram (post-nomogram phase), which titrates insulin dose based on the rate of change of plasma glucose values and uses multipliers to determine the new insulin infusion rate.MethodsHospitalized adults receiving an IV insulin infusion in our tertiary care medical center were enrolled in this study after informed consent was obtained. The study was an observational analysis conducted before and after implementation of the new insulin infusion nomo-gram. Measurements included episodes of hypoglycemia and incidence of the following errors in the insulin infusion process: (1) episodes of documented failure to increase insulin infusion rate despite persistent hyper-glycemia and (2) number of times the IV infusion was stopped without subcutaneous administration of insulin.ResultsOverall, 66 patients were analyzed (38 in the pre-nomogram phase and 28 in the post-nomogram phase). The new nomogram reduced by nearly 3-fold (from 0.89 ± 0.68 to 0.36 ± 0.49 occurrence per patient per 24 hours; P < 0.001) the mean incidence of failure to give insulin subcutaneously before discontinuation of IV insulin infusion. Moreover, the nomogram nearly eliminated the error of caregiver nonresponsiveness to persistent hyperglycemia: mean incidence 0.39 ± 0.65 occurrence per patient per 24 hours before implementation of the new nomogram versus 0.02 ± 0.09 afterward (P < 0.002). There was no statistically significant difference in episodes of hypoglycemia between the 2 study groups.ConclusionSafe IV administration of insulin through error prevention is essential. Implementation of a new IV insulin infusion nomogram, which adjusts insulin infusion using multipliers, reduces errors and improves glycemic control without increasing hypoglycemic episodes. (Endocr Pract. 2005;11:240-253) |
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