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 Table of Contents  
Year : 2016  |  Volume : 2  |  Issue : 2  |  Page : 154-158

Stamping out hypoglycemia in a surgical Intensive Care Unit: A multidisciplinary approach

1 Ohio State University Wexner Medical Center, Ohio State University, Columbus, OH, USA
2 Ohio State University Wexner Medical Center, Columbus, OH, USA
3 Beth Israel Deaconess Medical Center, Boston, MA, USA

Date of Submission08-Mar-2016
Date of Acceptance29-Mar-2016
Date of Web Publication28-Dec-2016

Correspondence Address:
Anthony Thomas Gerlach
368 Doan Hall, 410 West Tenth Ave, Columbus, OH 43210
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2455-5568.196866

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Context: Both hyperglycemia and hypoglycemia can significantly impact outcomes in critically ill patients. In the Intensive Care Unit (ICU), hypoglycemia is often the result of intensive insulin therapy.
Aims: The purpose of this study is to assess the impact of insulin infusion associated hypoglycemia using a multidisciplinary quality improvement approach with targeted education and real-time follow-up in a surgical ICU.
Setting and Design: A concurrent study in a surgical ICU of an academic medical center.
Materials and Methods: Our clinical pharmacists concurrently reviewed all cases of hypoglycemia (glucose <74 mg/dL) from March 16, 2010, to March 15, 2011. For cases of hypoglycemia judged related to insulin infusions, the pharmacists and unit clinical nurse specialists reviewed each case for compliance with institutional guidelines, and unit clinical nurse specialists or nurse managers provided targeted education to the bedside nurses involved. In August 2010, we performed unit wide nursing education on glycemic control and the insulin infusion guideline. Causes of hypoglycemic events were compared before and after education was completed.
Statistical Analysis: Fisher's exact test for nominal data.
Results: Four hundred and twenty-nine hypoglycemic events (188 patients) occurred in 2233 patient admissions. Most events involved administration of insulin (40%), including 106 (25%) involving insulin infusions and 59 (14%) associated with sliding scale insulin administration. Education significantly reduced the percentage of hypoglycemic events due to noncompliance (47% pre vs. 17% post, P = 0.002).
Conclusions: Education and unit feedback with concurrent staff follow-up were associated with a significant reduction in the rate of hypoglycemic events.
The following core competencies are addressed in this article: Patient care, practice-based learning and improvement.

Keywords: Adverse drug reactions, critically ill, hypoglycemia, insulin

How to cite this article:
Gerlach AT, MacDermott J, Newton C, Cook CH, Murphy CV. Stamping out hypoglycemia in a surgical Intensive Care Unit: A multidisciplinary approach. Int J Acad Med 2016;2:154-8

How to cite this URL:
Gerlach AT, MacDermott J, Newton C, Cook CH, Murphy CV. Stamping out hypoglycemia in a surgical Intensive Care Unit: A multidisciplinary approach. Int J Acad Med [serial online] 2016 [cited 2023 Jan 29];2:154-8. Available from: https://www.ijam-web.org/text.asp?2016/2/2/154/196866

  Introduction Top

In the decade since the publication of the landmark Leuven trial that demonstrated improved outcomes with strict glycemic control using an insulin infusion in critically ill patients, there have been numerous studies of glycemic control and outcomes in critically ill patients.[1] It is now thought that both untreated hyperglycemia and hypoglycemia should be avoided in critically ill patients.[2] The recently published society of critical care medicine guidelines for use of insulin infusions to manage hyperglycemia in critically ill patients recommends insulin infusion to treat glucose >150 mg/dL while avoiding hypoglycemia (glucose <70 mg/dL).[2]

Implementing strict glucose control protocols in the Intensive Care Unit (ICU) is “not that simple.”[3],[4] Many paper and electronic protocols have been published with similar results on mean or median glucose values, and most studies only report severe hypoglycemia.[5] One recent study concluded that even mild hypoglycemia (glucose <70 mg/dL) may be associated with increased mortality.[6] Perhaps, foremost of the challenge is the difficulty of managing the competing interests of controlling hyperglycemia while minimizing hypoglycemia. Bedside nursing is integral to successful insulin-based hyperglycemia therapy, being responsible for monitoring patient glucose and titration of insulin infusions. Nurses also play a vital role in detection and prevention of hypoglycemia. The purpose of this study is to assess the impact of a multidisciplinary quality improvement approach with targeted education and real-time follow-up on hypoglycemia associated with insulin infusions in a surgical ICU.

  Materials and Methods Top

This concurrent cohort study was conducted between March 16, 2010, and March 15, 2011, and was approved by the University Institutional Review Board in accordance with the ethical standards set forth in the Helsinki Declaration in 1975. All patients with hypoglycemia during admission to the surgical ICU at our University Medical Center were included. Hypoglycemia was defined by a glucose measurement <74 mg/dL either by bedside glucometer (Accu-chek ®) or via laboratory chemistry measurement. At the time of the data collection, glucose of 74 mg/dL was the lowest limit of normal in our laboratory. A clinical pharmacist (ATG or CVM) reviewed and categorized each case of hypoglycemia as insulin related (insulin infusion, sliding scale regular insulin, or long-acting insulin such as glargine) or noninsulin related. Hypoglycemic events not related to insulin were categorized as related to oral antihyperglycemics, abrupt discontinuation of continuous enteral or parenteral nutrition, liver insufficiency or spontaneous with or without a continuous dextrose/glucose source (i.e., maintenance intravenous fluids, continuous enteral nutrition, or parenteral nutrition). In cases of hypoglycemia induced by insulin, a clinical pharmacist and a clinical nurse specialist (JM or CN) determined if the institutional insulin infusion guidelines were followed [Table 1].[7] Noncompliance was defined as lack of monitoring glucose levels every hour, inappropriate titration of the insulin infusion based on the guideline, or no continuous dextrose source. For cases of hypoglycemia related to insulin infusion where the guidelines were not followed, the unit clinical nurse specialist or nurse manager provided one-on-one targeted education to involved bedside nurses. This education included infusion titration using the guideline and emphasized the risks to patients who experience even a single episode of hypoglycemia. After collecting data from March 16 to June 30, 2010, it was decided by our multidisciplinary surgical ICU safety committee to conduct unit wide nursing education in August 2010, with continuing concurrent review and real-time feedback for hypoglycemic episodes.
Table 1: Insulin Infusion Protocol

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The primary endpoint of this study was incidence of hypoglycemia related to noncompliance with the insulin infusion protocol before and after unit wide targeted education. Secondary endpoints included rates of hypoglycemia associated with etiology (insulin or noninsulin). Statistical analyses were performed using Statistical Package for Social Science (SPSS) version 19 (IBM Armonk, NY, USA). Nominal data were analyzed using Fisher's exact test and presented as a percentage. Continuous data were analyzed by Mann–Whitney U-test and presented as median (25–75% interquartile range). A P < 0.05 was considered statistically significant.

  Results Top

During the months prior to education, there were 164 hypoglycemic events identified. Roughly half of these events occurred as spontaneous hypoglycemic events in patients not receiving insulin or any antihyperglycemic medication (84 events or 51%) and 26 events (16%) were associated with hepatic insufficiency. There were 54 (33%) events associated with insulin including 33 (20%) with insulin infusion, 20 (12%) associated with sliding scale insulin, and 1 (1%) related to long-acting insulin. Of the events involving insulin infusions, almost half, i.e. 16 (48%) were related to noncompliance with the insulin infusion protocol. Five events occurred due to noncompliance with protocol adjustments; five events were associated with lack of hourly glucose measurements; two events followed noncompliance with both protocol adjustments and obtaining hourly glucose, and four events were related to patients not receiving a continuous source of dextrose. These data were reviewed by our multidisciplinary surgical ICU quality committee, and it was decided that nursing education on insulin infusion was needed.

During the 6 months after nursing education, there were 265 total events with 124 (47%) events occurring in patients not receiving insulin or any antihyperglycemic medication. There were 29 (11%) events in patients with hepatic insufficiency and one event associated with glyburide. The remaining 111 (42%) events were associated with insulin therapy including 72 (27%) events with insulin infusion, 36 (14%) events with sliding scale insulin, and 3 (1%) events with glargine [Table 2]. Events associated with protocol noncompliance occurred in 12 (17%) including 7 (10%) with protocol adjustment noncompliance and 5 (7%) with noncompliance with hourly glucose assessments. During the follow-up period, there were no events occurring due to patients not receiving a continuous dextrose source.
Table 2: Hypoglycemic events with Insulin Infusion

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Although there was no difference in the percentage of events involving insulin infusion (21% pre- and 27% post-, P = 0.14), after education was conducted, there was a significant reduction in the percentage of events due to noncompliance with the protocol (47% vs. 17%, P = 0.002; [Table 2]). Overall, there were no differences in median glucose values pre-education 68 (64–71) mg/dL versus posteducation 68 (60.5–70.5), P = 0.71. Likewise, there were no differences in median glucose values in those where the insulin infusion protocol was followed 68 (62–71) mg/dL compared to when it was not followed 66 (62–69.5) mg/dL, P = 0.77.

  Discussion Top

We demonstrated that staff education with feedback resulted in better compliance with our insulin infusion protocol. In the last decade, insulin infusion has become standard of care for the management of hyperglycemia in the critically ill patient but still carries a significant risk of hypoglycemia.[8],[9] Although our protocol had a less aggressive goal range (110–150 mg/dL) than many published protocols (80–110 mg/dL), we still observed a significant number of hypoglycemic events.[1],[6],[10],[11],[12],[13] Many factors influence glycemic control and may contribute to outcomes including target glucose range chosen, glycemic variability, patient type (surgical versus medical or mixed), timing and amount of nutritional support, and differences in insulin infusion protocols.[9] The challenge in any ICU is to balance efficacy and safety of insulin infusion.[9]

Performance improvement requires consistent data collection, measurement, and feedback.[14] Initially, we utilized the plan-do-study-act cycle with a clinical nurse specialist giving nursing feedback soon after noncompliance occurred.[14] Hypoglycemia data were also reviewed by our multi-disciplinary surgical ICU quality committee, and it became evident that we needed more aggressive nursing education for use of insulin infusions in our ICU. Working with nursing leadership and unit education committee, education was implemented and completed in August 2010. In addition, education on insulin infusions and hypoglycemia was developed for all new nurses going through critical care nursing orientation. We saw significant improvement in insulin infusion protocol compliance with noncompliance decreasing significantly from 43% to 17%, and lack of continuous dextrose decreased from 12% to 0%.

The use of insulin infusions can be complicated and difficult to perform, especially during dynamic critically illness. It is difficult to compare different protocols due to inter- and intra-patient variability that may impact protocol efficacy.[15] Most studies have described nurse-driven processes, with nurses responsible for glucose measurement and subsequent insulin titration. It has been demonstrated that timely and frequent glucose monitoring improves safety with insulin infusion.[16],[17],[18] Likewise, calculation errors can also lead to adverse effects of insulin infusion, especially when insulin adjustments are based on percent change. A recent report showed that experienced registered nurses with an average of 12.4 (±9.3) years of experience given a drug calculation test had mean scores of only 80%.[19] Computerized decision support has therefore been proposed and in some cases has shown improved glucose monitoring and calculation accuracy, but not all have demonstrated a reduction in hypoglycemia.[16],[20] The disadvantage of computerized support systems is their cost and requirement of information technology implementation and upkeep. They also may not assess other factors that affect glucose control, such as stopping enteral feeds for a procedure, and should not replace good clinical decision-making.

Continuous monitoring using the plan-do-study-act may also be necessary to improve safety with insulin infusion, regardless of using paper protocols or computerized programs.[14] Whether nurse-driven protocols or computer decision support is being used for insulin infusion, they need to be integrated into the nursing workflow and help enhance clinical decision making.[20] In our study, we found that after education and feedback the rate of noncompliance with our insulin infusion decreased significantly, but the overall rate of hypoglycemia attributable to insulin infusions did not change. Based on these results, we determined that our insulin infusion protocol required revisions in order to further reduce the risk of hypoglycemia. A multidisciplinary team including ICU physicians, nurses, pharmacists and an endocrinologist developed and piloted a revised insulin infusion protocol. A 6-month trial demonstrated that the revised protocol resulted in a reduction in hypoglycemia without negatively impacting mean glucose and time to glucose control.[21]

This study has several limitations. It is a retrospective, observational study and is not powered to detect differences in specific etiologic subcategories such as noncompliance with hourly glucose monitoring or calculation errors with insulin adjustments. During this study, the use of an insulin infusion was the most common method to treat hyperglycemia. Although insulin sliding scales were used, they were often individualized for each patient making them difficult to assess. Use of long-acting insulins, such as glargine, was discouraged in this time frame which explains the low rate of associated hypoglycemia. We did not collect data on all patients receiving insulin infusion, and were therefore unable to identify the true rate of noncompliance with insulin infusion or if noncompliance was independently associated with hypoglycemia. Finally, this study was conducted in a single surgical ICU study, and the results may not be applicable to other patients or institutions.

  Conclusions Top

Use of insulin infusion is complicated and requires ongoing quality performance improvement. Education and unit feedback with follow-up to staff in real time were associated with significantly reduced rate of hypoglycemia attributable to insulin infusion protocol noncompliance. Further studies are needed to determine the most effective methods for achieving glucose control with the lowest rate of hypoglycemia.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, et al. Intensive insulin therapy in critically ill patients. N Engl J Med 2001;345:1359-67.  Back to cited text no. 1
Jacobi J, Bircher N, Krinsley J, Agus M, Braithwaite SS, Deutschman C, et al. Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. Crit Care Med 2012;40:3251-76.  Back to cited text no. 2
Dossett LA, Collier B, Donahue R, Mowery NT, Dortch MJ, Guillamondegui O, et al. Intensive insulin therapy in practice: Can we do it? JPEN J Parenter Enteral Nutr 2009;33:14-20.  Back to cited text no. 3
Beishuizen A, Groeneveld AB. Implementing strict glucose control: It is not that simple. Crit Care Med 2006;34:3050-1.  Back to cited text no. 4
Krinsley J, Preiser JC. Intensive insulin therapy to control hyperglycemia in the critically ill: A look back at the evidence shapes the challenges ahead. Crit Care 2010;14:330.  Back to cited text no. 5
Krinsley JS, Schultz MJ, Spronk PE, Harmsen RE, van Braam Houckgeest F, van der Sluijs JP, et al. Mild hypoglycemia is independently associated with increased mortality in the critically ill. Crit Care 2011;15:R173.  Back to cited text no. 6
Murphy CV, Coffey R, Cook CH, Gerlach AT, Miller SF. Early glycemic control in critically ill patients with burn injury. J Burn Care Res 2011;32(6):583-90.  Back to cited text no. 7
DuBose JJ, Nomoto S, Higa L, Paolim R, Teixeira PG, Inaba K, et al. Nursing involvement improves compliance with tight blood glucose control in the trauma ICU: A prospective observational study. Intensive Crit Care Nurs 2009;25:101-7.  Back to cited text no. 8
May AK, Kauffmann RM, Collier BR. The place for glycemic control in the surgical patient. Surg Infect (Larchmt) 2011;12:405-18.  Back to cited text no. 9
Preiser JC, Devos P, Ruiz-Santana S, Mélot C, Annane D, Groeneveld J, et al. A prospective randomised multi-centre controlled trial on tight glucose control by intensive insulin therapy in adult intensive care units: The Glucontrol study. Intensive Care Med 2009;35:1738-48.  Back to cited text no. 10
Arabi YM, Dabbagh OC, Tamim HM, Al-Shimemeri AA, Memish ZA, Haddad SH, et al. Intensive versus conventional insulin therapy: A randomized controlled trial in medical and surgical critically ill patients. Crit Care Med 2008;36:3190-7.  Back to cited text no. 11
COIITSS Study Investigators, Annane D, Cariou A, Maxime V, Azoulay E, D'honneur G, et al. Corticosteroid treatment and intensive insulin therapy for septic shock in adults: A randomized controlled trial. JAMA 2010;303:341-8.  Back to cited text no. 12
NICE-SUGAR Study Investigators, Finfer S, Chittock DR, Su SY, Blair D, Foster D, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009;360:1283-97.  Back to cited text no. 13
Schorr C. Performance improvement in the management of sepsis. Crit Care Nurs Clin North Am 2011;23:203-13.  Back to cited text no. 14
Chase JG, Le Compte AJ, Suhaimi F, Shaw GM, Lynn A, Lin J, et al. Tight glycemic control in critical care – The leading role of insulin sensitivity and patient variability: A review and model-based analysis. Comput Methods Programs Biomed 2011;102:156-71.  Back to cited text no. 15
Eslami S, de Keizer NF, Dongelmans DA, de Jonge E, Schultz MJ, Abu-Hanna A. Effects of two different levels of computerized decision support on blood glucose regulation in critically ill patients. Int J Med Inform 2012;81:53-60.  Back to cited text no. 16
Garg R, Jarry A, Pendergrass M. Delay in blood glucose monitoring during an insulin infusion protocol is associated with increased risk of hypoglycemia in intensive care units. J Hosp Med 2009;4:E5-7.  Back to cited text no. 17
Juneja R, Roudebush CP, Nasraway SA, Golas AA, Jacobi J, Carroll J, et al. Computerized intensive insulin dosing can mitigate hypoglycemia and achieve tight glycemic control when glucose measurement is performed frequently and on time. Crit Care 2009;13:R163.  Back to cited text no. 18
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Eslami S, Abu-Hanna A, de Jonge E, de Keizer NF. Tight glycemic control and computerized decision-support systems: A systematic review. Intensive Care Med 2009;35:1505-17.  Back to cited text no. 20
Murphy C, Mac Dermott J, Vermillion B, St. Clair J, Weber M, Dungan KM, et al. Multidisciplinary approach to minimizing hypoglycemia: The impact of a revised nursing driven insulin infusion protocol. Crit Care Med 2012;40 Suppl1:304.  Back to cited text no. 21


  [Table 1], [Table 2]


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