Implementing Intensive Insulin Therapy: Development and Audit of the Bath Insulin Protocol

Abstract

Intensive insulin therapy to control blood glucose has been found to reduce mortality among critically ill patients in a surgical intensive care unit, though a simple prescriptive insulin infusion protocol to achieve this has not been published previously. This study documents the development and routine use of a simple prescriptive intravenous insulin infusion protocol for critically ill patients and compares the results with previous practice. During development the protocol was optimized and practical issues of implementation addressed. The optimized protocol was then used for all ICU admissions, and a prospectively defined retrospective chart audit performed for the first month of use. Results were compared with a similar time period the previous year. In September 2002, 27 admissions were started on the protocol. Blood glucose for the time on the protocol had a median value of 6.2 (IQR 5.9-7.1) mmol/l compared with 9. 2 (IQR 8.1-10.2) mmol/l for those on insulin in 2001. Blood glucose for the whole ICU stay for those on the protocol in 2002 had a median value of 6.6 (IQR 6.0-7.4) mmol/l compared with 8.6 (IQR 8.0-9.4) mmol/l in 2001. Blood glucose for all ICU patients in 2002 ) mmol/l in 2001.Three blood glucose recordings were less than 2.2 mmol/l in September 2002. This study provides initial effectiveness and safety data for the Bath Insulin Protocol. Further audits in a larger patient population are now needed.

Comparison of Three Protocols for Tight Glycemic Control in Cardiac Surgery Patients

“…We performed a monocenter randomized trial and compared a protocol based on the absolute glucose value, the Matias protocol (15,17); a protocol based on the relative glucose change, the Bath protocol (19); and a computer-based model predictive control algorithm with variable sampling rate (eMPC) (16) developed within the 6th Framework Programme e-Health Project “Closed Loop Insulin Infusion for Critically Ill Patients.”…”

Introducing intensive insulin therapy: the nursing perspective

“…After 6 months of development, the final protocol was introduced in all patients who fulfilled the criteria for its use. The final protocol and an audit of the first month of its use have been published (Laver et al ., 2004). The ethical committee of our hospital was consulted but did not think that formal approval was necessary for this work as it was putting evidence into practice.…”

“…To remove the need for clinical judgement (and the inherent errors it evokes), we decided to develop a nurse‐lead prescriptive insulin infusion protocol to be used for IIT on all of our critical care patients. The technical details of the Bath Insulin Protocol and initial audit of its use have been published previously (Laver et al ., 2004). The current paper chronicles the development, difficulties encountered and solutions found from a nursing perspective.…”

Sepsis strategies: an ICU package?

“…Royal United Hospital Bath is the first ICU in UK to produce a paper outlining the implementation of intensive insulin therapy for the critically ill through a quantitative and qualitative audit of 79 patients and includes development of their own protocol. They conclude that early data suggests that they have achieved effective blood glucose control but caution against implementation of the protocol until effectiveness and safety has been audited on a larger patient population (Laver et al ., 2004).…”