title: Implementation of a safe and effective insulin infusion protocol in a medical intensive care unit.
abstract: OBJECTIVE
  In a recent randomized controlled trial, lowering blood glucose levels to 80-110 mg/dl improved clinical outcomes in critically ill patients. In that study, the insulin infusion protocol (IIP) used to normalize blood glucose levels provided valuable guidelines for adjusting insulin therapy. In our hands, however, ongoing expert supervision was required to effectively manage the insulin infusions. This work describes our early experience with a safe, effective, nurse-implemented IIP that provides detailed insulin dosing instructions and requires minimal physician input.
  
  
  METHODS
  We collected data from 52 medical intensive care unit (MICU) patients who were placed on the IIP. Blood glucose levels were the primary outcome measurement. Relevant clinical variables and insulin requirements were also recorded. MICU nurses were surveyed regarding their experience with the IIP.
  
  
  RESULTS
  To date, our IIP has been employed 69 times in 52 patients admitted to an MICU. Using the IIP, the median time to reach target blood glucose levels (100-139 mg/dl) was 9 h. Once blood glucose levels fell below 140 mg/dl, 52% of 5,808 subsequent hourly blood glucose values fell within our narrow target range; 66% within a "clinically desirable" range of 80-139 mg/dl; and 93% within a "clinically acceptable" range of 80-199 mg/dl. Only 20 (0.3%) blood glucose values were <60 mg/dl, none of which resulted in clinically significant adverse events. In general, the IIP was readily accepted by our MICU nursing staff, most of whom rated the protocol as both clinically effective and easy to use.
  
  
  CONCLUSIONS
  Our nurse-implemented IIP is safe and effective in improving glycemic control in critically ill patients.
authors.affiliation: Department of Internal Medicine, Section of Endocrinology, Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut 06520, USA.
authors.forename: Philip A
authors.initials: PA
authors.lastname: Goldberg
authors.forename: Mark D
authors.initials: MD
authors.lastname: Siegel
authors.forename: Robert S
authors.initials: RS
authors.lastname: Sherwin
authors.forename: Joshua I
authors.initials: JI
authors.lastname: Halickman
authors.forename: Michelle
authors.initials: M
authors.lastname: Lee
authors.forename: Valerie A
authors.initials: VA
authors.lastname: Bailey
authors.forename: Sandy L
authors.initials: SL
authors.lastname: Lee
authors.forename: James D
authors.initials: JD
authors.lastname: Dziura
authors.forename: Silvio E
authors.initials: SE
authors.lastname: Inzucchi
mesh_terms: D018806:APACHE; D000328:Adult; D000368:Aged; D001786:Blood Glucose / Q000378:metabolism; D003237:Connecticut; D005260:Female; D006801:Humans; D007332:Insulin Infusion Systems / Q000592:standards*; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D044469:Racial Groups; D015203:Reproducibility of Results; D012449:Safety
chemical_list: D001786:Blood Glucose