Implementing an intravenous insulin infusion protocol in the intensive care unit

Rea, Rhonda S.; Donihi, Amy C.; Bobeck, MaryBeth; Herout, Peter; McKaveney, Teresa P.; Kane‐Gill, Sandra L.; Korytkowski, Mary T.

doi:10.2146/ajhp060014

Cited by 44 publications

(33 citation statements)

References 25 publications

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“…An extensive review of the merits and deficiencies of published protocols is beyond the intent of this statement, and the reader is referred to several available reports and reviews (364–366). Continued education of staff with periodic ongoing review of patient data are critical for successful implementation of any insulin protocol (364–366). …”

Section: Diabetes Care In Specific Settingsmentioning

confidence: 99%

Standards of Medical Care in Diabetes—2010

Basevi¹

2010

Diabetes Care

2,732

1,281

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Section: Diabetes Care In Specific Settingsmentioning

confidence: 99%

Standards of Medical Care in Diabetes—2010

Basevi¹

2010

Diabetes Care

2,732

1,281

View full text Add to dashboard Cite

show abstract

“…Thus, most insulin algorithms seem appropriate alternatives for the management of hyperglycemia in critically ill patients, and the choice depends on physician preferences and cost considerations. 132,139,140 …”

Section: Pharmacologic Treatment Of Inpatient Hyperglycemiamentioning

confidence: 99%

Insulin Therapy for the Management of Hyperglycemia in Hospitalized Patients

McDonnell¹,

Umpiérrez²

2012

Endocrinology and Metabolism Clinics of North America

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It has long been established that hyperglycemia with or without a prior diagnosis of diabetes increases both mortality and disease-specific morbidity in hospitalized patients1–4 and that goal-directed insulin therapy can improve outcomes.5–9 During the past decade, since the widespread institutional adoption of intensified insulin protocols after the publication of a landmark trial,5,10 the pendulum in the inpatient diabetes literature has swung away from achieving intensive glucose control and toward more moderate and individualized glycemic targets.11,12 This change in clinical practice is the result of several factors, including challenges faced by hospitals to coordinate glycemic control across all levels of care,13,14 publication of negative prospective trials,15,16 revised recommendations from professional organizations,17,18 and increasing evidence on the deleterious effect of hypoglycemia.19–22 This article reviews the pathophysiology of hyperglycemia during illness, the mechanisms for increased complications and mortality due to hyperglycemia and hypoglycemia, beneficial mechanistic effects of insulin therapy and provides updated recommendations for the inpatient management of diabetes in the critical care setting and in the general medicine and surgical settings.23,24

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“…Clinicians used three IIT CDSS mechanisms: 1) modules embedded within existing primary clinical information systems, including care provider order entry (CPOE) systems, that are accessible from hospital workstations and store blood glucose and insulin dosing data in clinical data repositories (CDR) [8, 9, 11, 14, 16, 48, 49]; 2) “calculators” accessible on a hospital network that do not store data in a CDR [15, 50] and may require additional documentation in a clinical information system [18] and/or use of a preprinted order set [45]; and 3) applications installed on standalone computers1 [14, 49]. Few studies reported location of hospital workstations [48], electronic data interchange with patient monitoring equipment [48], and use of other clinical information systems that are related to or may affect IIT CDSS, workflow, or care processes (e.g.…”

Section: Literature Review Of Computer-based Intensive Insulin Therapmentioning

confidence: 99%

“…Clinicians used handheld glucometers [8, 9, 13, 15-17, 48, 50], non-handheld blood gas analyzers [14, 49], and a combination of both [18] to obtain blood glucose measurements. The importance of handheld glucometers was demonstrated by additional glucometer investment before implementation [18], shortages during implementation [50], and the mechanical failure of a single non-handheld blood gas analyzer temporarily halting protocol use [14].…”

Section: Literature Review Of Computer-based Intensive Insulin Therapmentioning

confidence: 99%

Social, organizational, and contextual characteristics of clinical decision support systems for intensive insulin therapy: A literature review and case study

Campion

Waitman

May

et al. 2010

International Journal of Medical Informatics

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Introduction: Evaluations of computerized clinical decision support systems (CDSS) typically focus on clinical performance changes and do not include social, organizational, and contextual characteristics explaining use and effectiveness. Studies of CDSS for intensive insulin therapy (IIT) are no exception, and the literature lacks an understanding of effective computer-based IIT implementation and operation. Results: This paper presents (1) a literature review of computer-based IIT evaluations through the lens of institutional theory, a discipline from sociology and organization studies, to demonstrate the inconsistent reporting of workflow and care process execution and (2) a single-site case study to illustrate how computer-based IIT requires substantial organizational change and creates additional complexity with unintended consequences including error. Discussion: Computer-based IIT requires organizational commitment and attention to site-specific technology, workflow, and care processes to achieve intensive insulin therapy goals. The complex interaction between clinicians, blood glucose testing devices, and CDSS may contribute to workflow inefficiency and error. Evaluations rarely focus on the perspective of nurses, the primary users of computer-based IIT whose knowledge can potentially lead to process and care improvements. Conclusion: This paper addresses a gap in the literature concerning the social, organizational, and contextual characteristics of CDSS in general and for intensive insulin therapy specifically. Additionally, this paper identifies areas for future research to define optimal computer-based IIT process execution: the frequency and effect of manual data entry error of blood glucose values, the frequency and effect of nurse overrides of CDSS insulin dosing recommendations, and comprehensive ethnographic study of CDSS for IIT.

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Implementing an intravenous insulin infusion protocol in the intensive care unit

Cited by 44 publications

References 25 publications

Standards of Medical Care in Diabetes—2010

Standards of Medical Care in Diabetes—2010

Insulin Therapy for the Management of Hyperglycemia in Hospitalized Patients

Social, organizational, and contextual characteristics of clinical decision support systems for intensive insulin therapy: A literature review and case study

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