Improving IV Insulin Administration in a Community Hospital

The house-wide IV insulin protocol at Wyoming Medical Center achieved suboptimal results including unacceptable error rates and unacceptable rates of hypo and hyperglycemia. Therefore, the protocol was revised twice. However, each revision still achieved suboptimal rates of hypo and hyperglycemia and medication errors.

Thus, it was decided to implement a computer glucose monitoring system or CGMS to improve upon the deficiencies of the IV insulin paper protocol. After implementation of the CGMS patients on IV insulin infusions had substantially lower rates of hypoglycemia, hyperglycemia and increased rates of glycemic readings in the goal range. Ultimately, results can be obtained.

That show decreases in the rates of clinical hypoglycemia, severe hypoglycemia and hyperglycemia, and increases in time in the glycemic goal range through implementation of A-C-G-M-S as compared to the use of IV insulin paper protocols. The main advantage of the computerized glucose monitoring system over IV insulin paper protocols is that they're easier to use. They're more effective at managing glucose.

When you're using a computerized glucose monitoring system, you get less hypoglycemia, less hyperglycemia, and more time within the target goal range. The initial house wide IV insulin paper protocols at Wyoming Medical Center were modeled after the initial Vandenberg study. We did not receive the results we'd been expecting with that, so we then revised the protocol following the trends works even through a second revision of that, we did not receive the results we'd been expecting.

It was decided to implement a computerized glucose management system to improve upon the deficiencies of the IV insulin paper protocol. So let's get started to seeing how the CGMS is used. Prior to utilizing computerized glucose monitoring, several key steps must be employed.

One order sets based on CGMS templates for hyperglycemia and diabetic ketoacidosis must be developed. Two blood glucose target ranges must be determined, and three, the pre-printed orders from pharmacy and endocrinology then must be uploaded onto the hospital intranet. After opening the program, find the patient of interest by clicking on the search for new patient link then in the search for new patient pop-up window.

Log in by entering the user ID and password after clicking, okay, enter the account number into the account number window of the search for new patient screen. Then after clicking search, the new patient information will appear, allowing the patient to be selected. The software uses mathematical modeling to calculate a patient specific physiologic insulin dosing curve based on the input of patient specific blood glucose concentrations.

Using 33 algorithms, the program analyzes and interprets the patient's previous glucose readings incorporating the four most recent readings, thus after clicking, okay to add the patient, enter the patient's clinical information such as the patient's diabetic status wait and creatinine level, and whether the patient has received any oral or IV steroids in the past 24 hours into the appropriate boxes on the demographic screen as these data affect blood glucose levels and therefore factor into the system's initial calculations. Once the clinical data has been entered, click save and continue to bring up the initial patient record screen and then enter the patient's initial glucose reading. A box will then pop up asking for verification of the glucose that was entered, enter the glucose level again and click okay.

Now check that all the patient information is correct in the green confirmation popup screen, and click okay. Next, a yellow calculation screen that tells how much of an insulin bolus to give if necessary, at what rate to run the infusion and when to check the next glucose will appear When subsequent glucose readings are entered. Endo tool asks for confirmation that the recommended insulin dose was indeed administered, and if any extra calories were given, that could have affected the patient's glucose reading.

Adjust the insulin dosage and calorie information in the green confirmation screen as necessary after clicking. Okay, a yellow calculation screen with insulin bolus if necessary, insulin infusion rate and next check time information will appear after making note of these recommendations. Click finished.

When checking glucose early, endo tool will ask for verification of the request to ensure that the patient has not been selected in error. If the correct patient has been selected, click okay. If unexpected glucose values are entered, or in some cases if expected information is missing, a clinical advisory window will pop up.

After noting the warning information, click continue to make any necessary changes to the patient information. Click on the glucose record tab to find a record of each patient's glucoses insulin bolus amounts, insulin infusion rates, intervals between checks, and the name of the nurse who entered these data. When a patient needs to go off the unit to an area where endo tool isn't available, click on the print patient reports slash link in the box at the top of the column on the left hand side of the home screen, select the IV insulin drip orders for temporary use without endo tool box and click okay to display the recommendations for adjusting the IV insulin infusion until the patient returns and can be placed back on endo tool.

Then click on the printer icon in the left upper corner to print. Finally, when the patient is ready to transition off of Endo tool and over to subcutaneous insulin endo tool will provide transition dose recommendations for the first 24 hours. These transition orders are also accessed from the print patient reports slash orders link.

Select fixed insulin order options and then select the appropriate transition order. The initial paper intravenous insulin protocols developed at Wyoming Medical Center called for tight glucose control of 80 to 110 milligrams per deciliter in ICU patients and more liberal glucose control of 95 to 120 milligrams per deciliter in non ICU patients. After the first revision of the paper protocol, one third of all blood glucose readings were above 180 milligrams per deciliter while only 2.5%were below 80 milligrams per deciliter and 0.3%were below 60 milligrams per deciliter.

Due to the unacceptable number of errors committed by staff, the facility-wide IV insulin paper protocols were modified twice. Ultimately, it was determined that use of the original paper protocol was associated with the 16.5%prevalence of blood glucose readings of less than or equal to 94 milligrams per deciliter, and a 4.2%prevalence of readings of less than 70 milligrams per deciliter. Of particular concern was the finding that 85%of hypoglycemic events that is a blood glucose reading of less than 70 milligrams per deciliter were not due to the actual protocol, but resulted from error in utilizing the paper protocol.

Further investigation uncovered the multiple causes of these errors. For example, omitting the insulin bolus and not changing the rate of the insulin infusion when instructed to do so in the protocol accounted for 55%of all errors. The frequency of staff deviating from the revised protocol also was examined.

There were a total of 317 protocol deviations, only 7%of which were clinically justifiable, meaning that protocol deviation without clinical justification occurred at a rate of one deviation per every three hours on the protocol. Even after the second revision, the rates of hypoglycemia considered to be less than 60 milligrams per deciliter and hyperglycemia. Blood glucose measuring greater than 180 milligrams per deciliter continued to be very high with use of the paper protocol at 4.7%and 26.3%respectively of concern.

Again, the deviations from protocol without clinical justification were still very high at 83.5%after the second revision, meaning that deviations from protocol without clinical justification occurred at a rate of one per every four hours. By revising the protocol in an attempt to explicitly clear up ambiguous areas, the complexity of the protocol had increased leading to difficulty with nursing staff correctly utilizing it. Conversely, a substantial increase in the time spent within the target blood glucose concentration range, as well as a decrease in the prevalence of severe hypoglycemia determined as a blood glucose reading of less than 40 milligrams per deciliter.

Clinical hypoglycemia, a blood glucose of less than 70 milligrams per deciliter and hyperglycemia, blood glucose greater than 180 milligrams per deciliter was witnessed in the first five months of CGMS use. Examining the actual blood glucose concentrations achieved through use of the various dosing protocols provided interesting results use of the initial paper protocol, including use after the two revisions, produce substantially higher hypoglycemia rates, blood glucose below 60 or 70 milligrams per deciliter compared with the CGMS protocol. In addition, compared with the paper protocols, the CGMS protocol maintained blood glucose concentrations within the target range for a much longer proportion of treatment time, even though the system is designed to customize IV insulin dosing to an individual patient's needs.

Upon implementation of the CGMS, there was some initial resistance from physicians until they felt that they could understand and trust the software. At times, the system would recommend much higher infusion rates and bolus doses to keep the patient in the goal range than are commonly recommended by paper protocols. The staff has since become comfortable with the CGMS recommendations and rarely deviates from suggested infusion rates or bolus doses.

In particular, the resistance diminished once the medical staff saw how easy the system was to use and how effective it was in controlling blood glucose concentrations, resulting in tighter glycemic control under the new computer glycemic management system, and achieving target concentrations in greater than 75%of all readings. After implementation of the computerized glucose management system, patients on IV insulin infusions had substantially lower rates of hypoglycemia and hyperglycemia, and they had increased rates of glycemic readings in the goal range.