Optimizing Hospital Use of Intravenous Insulin Therapy: Improved Management of Hyperglycemia and Error Reduction With a New Nomogram

Abstract

To assess the efficacy and safety of intravenous (IV) insulin administration with use of our institution's old protocol (pre-nomogram phase) as compared with our new insulin nomogram (post-nomogram phase), which titrates insulin dose based on the rate of change of plasma glucose values and uses multipliers to determine the new insulin infusion rate. Hospitalized adults receiving an IV insulin infusion in our tertiary care medical center were enrolled in this study after informed consent was obtained. The study was an observational analysis conducted before and after implementation of the new insulin infusion nomogram. Measurements included episodes of hypoglycemia and incidence of the following errors in the insulin infusion process: (1) episodes of documented failure to increase insulin infusion rate despite persistent hyperglycemia and (2) number of times the IV infusion was stopped without subcutaneous administration of insulin. Overall, 66 patients were analyzed (38 in the pre-nomogram phase and 28 in the post-nomogram phase). The new nomogram reduced by nearly 3-fold (from 0.89 +/- 0.68 to 0.36 +/- 0.49 occurrence per patient per 24 hours; P<0.001) the mean incidence of failure to give insulin subcutaneously before discontinuation of IV insulin infusion. Moreover, the nomogram nearly eliminated the error of caregiver nonresponsiveness to persistent hyperglycemia: mean incidence 0.39 +/- 0.65 occurrence per patient per 24 hours before implementation of the new nomogram versus 0.02 +/- 0.09 afterward (P<0.002). There was no statistically significant difference in episodes of hypoglycemia between the 2 study groups. Safe IV administration of insulin through error prevention is essential. Implementation of a new IV insulin infusion nomogram, which adjusts insulin infusion using multipliers, reduces errors and improves glycemic control without increasing hypoglycemic episodes.