title: Impact of a Paper-Based Dynamic Insulin Infusion Protocol on Glycemic Variability, Time in Target, and Hypoglycemic Risk: A Stepped Wedge Trial in Medical Intensive Care Unit Patients.
abstract: Stress-induced hyperglycemia is a common feature of intensive care unit (ICU) patients. Besides mean blood glucose (BG) level, glucose variability and hypoglycemia have been highlighted as independent predictors of ICU and hospital mortality. Recent ICU recommendations suggest using insulin infusion protocols that can minimize glucose variability and hypoglycemic risk. Our aim was to assess the efficacy, safety, and acceptance by nurses of a paper-based simple dynamic insulin protocol compared with those by nurses of a paper-based static protocol.
  
  
  
  This is a 1 year stepped-wedge study that compared a static sliding scale protocol (SP - static protocol) with a validated dynamic paper-based intravenous insulin infusion protocol (DP - dynamic protocol) in medical ICU patients of a single university hospital. Patients with stress-induced hyperglycemia >9.9 mmol/L and ≥48 h intravenous insulin infusion were included in this trial.
  
  
  
  One hundred thirty-one patients were included and received continuous intravenous insulin infusion managed with SP (n = 65) or DP (n = 66). Glucose variability was significantly higher in the SP group than in the DP group (mean average glucose excursion index: 0.90 [0.00-1.91] mmol/L vs. 0.00 [0.00-0.90] mmol/L, respectively; P = 0.001). The percentage of time spent in the target range (7.7-9.9 mmol/L) was lower in the SP group than in the DP group (42.5% [28.8%-54.2%] vs. 47.5% [36.6%-57.1%]; P = 0.037). Low BG (<4.4 mmol/L) and hypoglycemia (<3.3 mmol/L) were more frequent in the SP group than in the DP group. According to a satisfaction survey, this protocol was well accepted by nurses.
  
  
  
  Our simple and feasible paper-based, dynamic insulin infusion protocol reduced glycemic variability and hypoglycemic risk in a medical ICU.
authors.affiliation: 1 Diabetes Care Unit, University Hospital of Caen , Caen, France .
authors.forename: Antoine
authors.initials: A
authors.lastname: Clergeau
authors.affiliation: 2 Biostatistic Unit, University Hospital of Caen , Caen, France .
authors.forename: Jean-Jacques
authors.initials: JJ
authors.lastname: Parienti
authors.affiliation: 1 Diabetes Care Unit, University Hospital of Caen , Caen, France .
authors.forename: Yves
authors.initials: Y
authors.lastname: Reznik
authors.affiliation: 3 Intensive Care Unit, University Hospital of Caen , Caen, France .
authors.forename: Deborah
authors.initials: D
authors.lastname: Clergeau
authors.affiliation: 3 Intensive Care Unit, University Hospital of Caen , Caen, France .
authors.forename: Amelie
authors.initials: A
authors.lastname: Seguin
authors.affiliation: 3 Intensive Care Unit, University Hospital of Caen , Caen, France .
authors.forename: Xavier
authors.initials: X
authors.lastname: Valette
authors.affiliation: 3 Intensive Care Unit, University Hospital of Caen , Caen, France .
authors.forename: Damien
authors.initials: D
authors.lastname: du Cheyron
authors.affiliation: 1 Diabetes Care Unit, University Hospital of Caen , Caen, France .
authors.forename: Michael
authors.initials: M
authors.lastname: Joubert
mesh_terms: D000368:Aged; D001786:Blood Glucose / Q000032:analysis*; D003422:Critical Care / Q000379:methods; D005260:Female; D006801:Humans; D006943:Hyperglycemia / Q000097:blood / Q000188:drug therapy*; D007004:Hypoglycemic Agents / Q000008:administration & dosage* / Q000627:therapeutic use; D007262:Infusions, Intravenous; D007328:Insulin / Q000008:administration & dosage* / Q000627:therapeutic use; D007332:Insulin Infusion Systems; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D016896:Treatment Outcome
chemical_list: D001786:Blood Glucose; D007004:Hypoglycemic Agents; D007328:Insulin
keywords: Dynamic insulin infusion protocol; Glycemic variability; Hypoglycemia; Intensive care unit; Nurse care; Stress hyperglycemia