Long-term safety and efficacy of a universal nursing-run intravenous insulin guideline

Despite the plethora of data in the critical care setting, there are few studies to guide clinicians in the hospitalwide care of patients with hyperglycemia.

Patients 18 years of age and older who had a discharge diagnosis code for diabetes were admitted between January 1, 2005, and December 31, 2010, and received an insulin infusion for any reason were included in the analysis. Patients were receiving noncritical care or cardiac care (with interchangeable critical and noncritical care capacity). The effect of an insulin infusion guideline introduced in 2006 with a target glucose of 5.6-8.3 mmol/L was measured. Hyperglycemic (> 11.1 mmol/L) and hypoglycemic (< 3.9 or < 2.8 mmol/L) events were analyzed using multivariable models.

After adjusting for age, gender, race, and nutrition, there was a significant decrease in time to first glucose < 8.3 mmol/L in hours (T8.3; p = .01) and hyperglycemia (p < .0001) in the year following implementation of the guideline in cardiac but not noncritical beds, which persisted through 2010. There was a significant decrease in hypoglycemic events by Year 3 in cardiac beds and by Year 5 in noncritical beds. Compared with patients who received nothing by mouth, patients eating discrete meals had significantly longer T8.3, greater variability, and more hyperglycemic and hypoglycemic events in cardiac and noncritical beds.

Following the hospitalwide implementation of a nursing-run insulin infusion guideline, rapid, stable reduction in hyperglycemia was achieved in cardiac beds (having interchangeable ICU and non-ICU status), and the frequency of hypoglycemia steadily decreased over time in both cardiac and noncardiac beds. Oral intake and enteral feeding were associated with worse glycemic control.