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CRITICAL CARE

Evaluation of Compliance with a Paper-based, Multiplication-factor, Intravenous Insulin Protocol

Senior Clinical Pharmacist, Department of Pharmacy, Pharmacy Administration; L-2, Brigham and Women's Hospital, Boston, MA

Paul M Szumita, PharmD BCPS

Clinical Pharmacy Practice Manager, Department of Pharmacy, Pharmacy Administration; L-2, Brigham and Women's Hospital

Bonnie C Greenwood, PharmD BCPS

Burn/Trauma Clinical Pharmacy Specialist, Department of Pharmacy, Pharmacy Administration; L-2, Brigham and Women's Hospital

Merri L Pendergrass, MD PhD

National Practice Leader, Diabetes, Medco, Colleyville, TX

Reprints: Dr. Cyrus, Department of Pharmacy, Pharmacy Administration; L-2, Brigham and Women's Hospital, 75 Francis St., Boston, MA 02115, fax 617/566-2396, rcyrus{at}partners.org

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.

Key Words: critical care, glucose, insulin, intensive care unit, intensive glucose management, intravenous protocol

Published Online, August 4, 2009. www.theannals.com, DOI 10.1345/aph.1M060