Collaborative development of an insulin nomogram for intensive insulin therapy

A significant reduction in morbidity and mortality can be achieved by using intensive insulin therapy to achieve normoglycemia in the critically ill patient. Nurses hourly titrate insulin infusion rates using protocols, most often in chart form, to guide practice. Despite the reported development of several intensive insulin protocols, information about the accuracy, practicality, ease of calculation, and preferences of critical care nurses have not been studied. The purpose of this study was to test a newly developed nomogram to determine if it was clinically practical, easily understood, and more quickly and accurately used than existing protocols in chart form. Three cohorts of nurses (N = 153), with an average of 9 years experience in critical care, performed calculations of insulin doses on the basis of hypothetical patient data, using chart and nomogram protocols. Time, accuracy, preference, and feedback were examined over all 3 phases. No statistical significance was found between the chart and nomogram methods regarding time to complete the calculations nor was there any significant effect of experience on the time it took to complete the calculations or the accuracy of the resultant answers. Overall, the accuracy of the calculations improved with each revision of the nomogram. The nurses did not have a preference of one tool over another but gave extensive feedback that helped refine the nomogram. The resultant nomogram was shown to be easy to use, helpful in improving the accuracy of insulin dosage calculation, and judged to be practical by the nurses who would use the tool at the bedside.