title: A review of the use of insulin protocols to maintain normoglycaemia in high dependency patients.
abstract: OBJECTIVE
  This paper critically examines the evidence base for and issues involved in the introduction of an insulin protocol to maintain normoglycaemia in patients within a medical/surgical high dependency ward.
  
  
  BACKGROUND
  A growing body of evidence has linked hyperglycaemia to worsened clinical outcomes. This has led to intravenous insulin protocols becoming a new standard of care in intensive care units. However, the use and benefits of insulin protocols within high dependency units have not yet been addressed in the literature.
  
  
  METHODS
  The literature was examined for the 10-year period up to January 2005. The databases searched were MEDLINE, OVID, CINHAL, the British Nursing Index, the EBSCO collection, the COCHRANE library, the Department of Health, and guidelines within the Scottish Intercollegiate Guidelines Network and National Institute for Clinical Excellence using the key words insulin, protocol, hyperglycaemia, critical care, intensive care and high dependency.
  
  
  RESULTS
  The literature reports that both medical and surgical intensive care patients treated with intravenous insulin protocols to maintain normoglycaemia experienced significantly reduced mortality and morbidity. Resulting hypoglycaemic episodes were limited with no incidence of patient deterioration. A review of published intravenous insulin protocols used in intensive care settings revealed their safe and effective use in nurse to patient ratios similar to those present in high dependency units.
  
  
  CONCLUSIONS
  In the light of this evidence, it would seem safe and ethically correct to enable high dependency patients to benefit from this cheap intervention. An insulin protocol tailored for the glycaemic control of high dependency patients has been suggested, although it may have to be commenced in conjunction with other fluid and nutrition protocols to safeguard the risk of hypoglycaemic events. Further research into the safety and benefit of insulin protocols in high dependency populations is required.
  
  
  CONCLUSIONS
  The stress of critical illness often leads to hyperglycaemia, which is linked to worsened clinical outcomes. Both medical and surgical intensive care patients treated with intravenous insulin protocols to maintain normoglycaemia experienced significantly reduced mortality and morbidity. This paper identifies that, to date, no research into the benefits of glycaemic control in high dependency populations has been published. The case for the introduction of insulin protocols into high dependency units is therefore examined and an insulin protocol suggested.
authors.affiliation: General High Dependency Unit, Royal Infirmary of Edinburgh, Edinburgh, Scotland. janey@whitehorn.info
authors.forename: L Jane
authors.initials: LJ
authors.lastname: Whitehorn
mesh_terms: D002985:Clinical Protocols; D016638:Critical Illness / Q000451:nursing; D006801:Humans; D006943:Hyperglycemia / Q000517:prevention & control*; D007262:Infusions, Intravenous; D007328:Insulin / Q000008:administration & dosage*; D007362:Intensive Care Units; D016019:Survival Analysis; D016896:Treatment Outcome
chemical_list: D007328:Insulin