Protocol Pilot

The percentage of glucoses below 70 mg/dl increased from 2%-3% using the four-column protocol to 4%-5% using the six-column protocol, as the percentage of glucoses between 70-150 mg/dl rose above 70%.

The main complaint from nurses relates to the need for frequent (hourly to twice hourly) glucose monitoring, which was also a complaint with earlier protocols in our institution.

The “Critical Care Adult Insulin Infusion” form used by staff at Southwest Washington Medical Center in Vancouver, Wash.

Discussion

These results compare favorably with those achieved by acknowledged leaders in critical care glycemic control in the United States.13 We have achieved them with the use of a safe column protocol that our critical care nurses are now comfortable using. The hypoglycemia rates with our protocol have been lower than those seen in some other published protocols. The Berghe protocol, for example, reported 5% of patients experiencing glucoses lower than or equal to 40 mg/dl, while our protocol resulted in 4%-5% of glucose values lower than 70 mg/dl.

Mortality rates in our ICU have fallen from 14% in September 2005 to 11% in February 2006 to 8% in August 2006. Although this decline in mortality has occurred over the range of time in which we have improved glycemic control in our ICU, multiple other mortality reduction initiatives, any or all of which could account for the decline, occurred simultaneously in our hospital; in addition, mortality rates were falling before the introduction of the new insulin infusion protocol.

Head-to-head comparisons of existing protocols, using agreed upon glucometrics such as time-to-goal range and degree of glycemic variability, are needed.14 Testing new protocols, including proactive insulin infusion adjustments at the time of administration of known caloric loads—such as antibiotics delivered as a bolus in D5W solution—or at the time of initiation of high dose steroids or epinephrine drips, may be a means to keep a higher percentage of blood sugars in range. Ultimately, continuous blood sensing devices with closed loop insulin infusion responses are desired.

For now, our protocol offers a user-friendly means of getting a high percentage of critical care patients into a reasonable glycemic range with a low risk of hypoglycemia. Others are free to use and/or modify it. TH

The authors work at Southwest Washington Medical Center, Vancouver, Wash.

References

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