Designing and Implementing Insulin Infusion
Protocols and Order Sets
Andrew J. Ahmann, MD, MSc1
Greg Maynard, MD, MSc2
1Department of Medicine, Division of Endocrinol-
ogy, Diabetes and Clinical Nutrition, Oregon
Health & Science University, Portland, Oregon.
2Department of Medicine, Division of Hospital
Medicine, University of California, San Diego,
Influential trials and guidelines supporting the value of glucose control in hospi-
tal settings, particularly in the intensive care and postoperative settings, has led
to the widespread adoption of intravenous infusions of human regular insulin. As
groups have attempted to study the outcomes or to explore improved methods
for improved glucose control, a number of insulin infusion protocols (IIPs) have
been reported and validated. Now, many institutions are attempting to translate
this experience into clinical practice in a systematic manner. The intent of this
discussion is to highlight the authors’ practical view of best practices in develop-
ment and use of IIPs.
As the implementation of IIPs has progressed, it has become apparent that
this is not a simple process. It requires a carefully planned, inclusive, and contin-
uous effort striving to attain effective glucose control while avoiding severe hypo-
glycemia. Whereas there are limitations in the literature comparing the IIPs, we
identify design elements and implementation methods that increase the chances
for staff acceptance and safe attainment of glycemic goals. Most importantly, this
must be a team effort with attention to the numerous potential pitfalls that can
disrupt the process and place patients at risk.
In many cases, it is best to start more conservatively and methodically in-
tensify the protocol. Continuous assessment of protocol errors, adverse events,
staff satisfaction, and outcomes is vital to overall success. Journal of Hospital
Medicine 2008;(5 Suppl):42–54. V V
C 2008 Society of Hospital Medicine.
KEYWORDS: intravenous infusion, insulin, critical care protocols, best practices.
sulin has always provided challenges for the rapid and pre-
dictable control of hyperglycemia in the acute care setting.
Conversely, intravenous infusion of human regular insulin pro-
vides a continuous and essentially immediate delivery mecha-
nism. Once in the circulation, insulin has a very short half-life of
about 5 to 7 minutes and a biological effect of about 20 min-
utes.1Intravenous insulin infusions are well-established in sev-
eral acute care settings including hyperglycemic emergencies,
perioperative glucose management, and glucose control during
labor and delivery.2,3
The beneficial effects seen in early trials of strict glycemic
control involving intensive care unit (ICU) patients4–7(particu-
larly cardiac surgery patients) and guidelines for inpatient glyce-
mic control8stimulated widespread interest in adopting insulin
infusion protocols (IIPs) focused on achieving strict glycemic
targets. The initial enthusiasm has been tempered by uneven
results in trials of tight glycemic control, concerns about the
effects of excessive hypoglycemia, and the resources needed to
he delayed and variable absorption of subcutaneous (SC) in-
No honoraria were paid to any authors for time
and expertise spent on the writing of this article.
Greg Maynard has received honoraria for speak-
ing engagements from Sanofi-Aventis.
Andrew Ahmann received honoraria for lectures
from Sanofi-Aventis, Eli Lilly, and Novo.
ª2008 Society of Hospital Medicine
Published online in Wiley InterScience (www.interscience.wiley.com).
implement and maintain an IIP.9Although consid-
erable controversy about the ideal glycemic target
for different patient populations exists, and will
likely continue for some time, this article is not a
review of the evidence for supporting 1 glycemic
target versus another. Regardless of the glycemic
accompanying program of monitoring are widely
endorsed for both safety and quality reasons.10–14
Most medical centers are at least attempting to
demonstrated better perfomance than SC regi-
mens15and physician-driven insulin infusions.16,17
In this article, we outline several variables in IIP
design and implementation and endorse several
aspects of design and implementation that will
likely result in improved staff acceptance and,
ultimately, a more safe and effective IIP.
PREPARING TO IMPLEMENT AN IIP
Building The Team
Implementing a medical center–wide standardized
insulin infusion order set with supporting policies,
protocols, monitoring standards, and the requisite
educational programs is a major task for any hos-
pital. This is not a simple maneuver involving
only 1 or 2 interested individuals and requires
much more than selecting a published protocol
and disseminating it to various patient care units.
Instead, to manage the full spectrum of diabetes
programs and protocols, an institution must con-
vene a multidisciplinary steering committee or
task force. This should include representation
from nursing, nursing administration, pharmacy,
nutrition services, and the quality improvement
department. Physicians should include hospital-
ists, intensivists, and endocrinologists but may
also involve anesthesiologists and surgeons, as ap-
plicable. At times, additional members may need
to be recruited according to project needs.
Identifying the Stakeholders and Current Practices
In developing or improving currently utilized IIPs,
the multidisciplinary committee would benefit
from careful background work before moving
forward. First, administrative and institutional
support must be secured to endorse uniform
standards for insulin infusions, and to provide the
important infrastructure needed to facilitate the
work involved. Clinical and administrative stake-
holders from the key departments then need to be
All insulin infusion orders and policies/proce-
dures presently used in the institution should be
identified and examined. The developers and/or
users of these order sets should be engaged in a
dialogue and encouraged to share their experi-
ences regarding their current practice and the at-
tendant work flow, glucose monitoring, and data
should be clearly addressed. Measurement sys-
tems for glycemic control, hypoglycemia, and in-
sulin use patterns should assess current practice
and the impact of subsequent modifications of
the protocol or initiation of new protocols. We
recommend using ‘‘glucometrics’’ consistent with
those endorsed by the Society of Hospital Medi-
cine (SHM) Glycemic Control Task Force else-
where in this supplement.18
Addressing the Burden of Change
Through this process, the committee will uncover
barriers, dysfunctional and inconsistent practices,
and individuals who will pose challenges. Identify-
ing these issues should not discourage the team,
but rather it should guide the interventional stra-
tegies, and help build consensus that change may
be required. There must be caution not to exclude
significant individuals simply because they resist
changes. Indeed, if they are included and have the
opportunity to contribute to the process, success
is much more likely.
It is important for process leaders to under-
stand the implications of what is proposed, particu-
larly for nursing services.19For example, it has been
shown that IIPs require about 5 minutes per patient
per hour for glucose monitoring and dose adjust-
ments.20Acknowledging and attempting to address
this burden proactively (often well over 2 hours per
day) can gain staff acceptance more effectively
than a laissez faire approach. In this regard, some
effort should be invested in nursing education of
the benefits of tight glycemic management on criti-
cal care outcomes. The difficult-to-quantify work
involved when patients’ blood glucose is not well
controlled (eg, paging physicians for stat insulin
orders) should also be part of this discussion.
Identifying and Addressing Barriers to IIP implementation
There are numerous potential barriers to imple-
mentation of IIPs. Table 1 identifies some of the
Implementing Insulin Infusion Protocols / Ahmann and Maynard S43
most frequent ones along with potential strategies
or solutions. Very common barriers include skepti-
cism surrounding the benefits of tight glycemic
control, fear of hypoglycemia, and difficulty agree-
ing on glycemic targets.
Whereas the national guidelines call for a gly-
cemic target in critical care areas with an upper
limit of 110 mg/dL, there is room for debate, and
tailoring of the glycemic target to fit individual
patient circumstances is often advisable. Starting
with a less aggressive glycemic target can be good
politics (and perhaps good medicine as well).
Once the higher glycemic targets are achieved
safely, it can pave the way for a more aggressive
Fear of hypoglycemia is one of the most
potent barriers to intensive insulin infusion imple-
mentation. Because hyperglycemia is such a com-
mon condition in critical care units, nursing and
physician staff may have developed a skewed view
of the definition of hypoglycemia, at times fearing
for their patient when the glucose values reach a
level of 100 mg/dL or so. Polling the nurses on
what they think their own fasting glucose levels
are, and then actually measuring them can be an
effective strategy (the nurses may be surprised
that the patient’s ‘‘scary’’ 90 mg/dL reading is
higher than their own). It should also be empha-
sized that properly designed and implemented
protocols may actually decrease the incidence of
hypoglycemia when compared to ‘‘standard care’’
which may involve individually and sometimes
improperly adjusted intravenous (IV) insulin (dis-
cussed further below).
CHOOSING AN IIP FOR YOUR HOSPITAL
See Table 2 for a comparison of several features
identified in selected published protocols.7,21–27
This is not a comprehensive list of all protocols
found in the literature. Rather, the authors con-
sider it representative of the various types of IIPs
Barriers to Effective Implementation and Utilization of Insulin Infusion Protocols, and Strategies to Address Them
Insufficient glucose meters to accommodate the increased
Nursing time requirements involved in monitoring and
? Purchase additional glucose meters.
? Ask the vendor to provide extra on-site replacement meters at no charge until they are activated.
? Get ancillary help to check glucose values
? eg, nurse assistants
? Make extra efforts to make protocols clear with few required calculations
? Avoid duplicate recording
? Consider meters requiring shorter time and a smaller sample (to avoid need for re-sampling)
? Utilize central lines or arterial lines.
? These tend to vary by < 10% from POC readings
? May not be available in non–critical care settings
? Educate on the benefit of glucose control and the true definition of hypoglycemia
? Measure staff fasting glucose levels to demonstrate normal range.
? Establish metrics and publicly report hypoglycemia event rates.
? Pilot IIP on small scale.
? Protocol and education for prevention of hypoglycemia.
? Compromise if needed on the glucose target
? eg, start with a higher goal such as 90-140 mg/dL.
? Others will be willing to lower the goal when feasibility is seen.
? Allow for different targets in different units if indicated
? maintain consistency in other respects.
? Identify a local nurse or physician champion within resistant site.
? Pilot the protocol in an area with least resistance
? Will gain momentum with initial success and adjustments
? Incorporate information systems personnel onto team
? Advocate for improved reporting capability with administrative leaders
? Use sampling methods to collect data until automated systems are available.
? Involvement of varied front line providers
? Check lists for important items to communicate on transfer/transport
? Common protocols/education for similar units
Requirement for uncomfortable frequent sticks
Staff fear of hypoglycemia
Difficulty gaining consensus on glycemic target
Focal points of resistance
Lack of integrated information and reporting systems
Multiple providers, hand offs, and opportunities for error and
communication breakdown, diffusion of responsibility for
S44Journal of Hospital Medicine Vol 3 / Issue 5 / Supplement 5 / September/October 2008
Characteristics of Selected Published Insulin Infusion Protocols
Time to ReachTarget
Van den Berghe7
? Initial and subsequent rates based
6 AM glucose 103 ? 19
5.1% of patient < 41 mg/
? Nurses had latitude
Van den Berghe21
? TPN standard with IIP
6 AM glucose 105
19% of patients < 41 mg/
? Initial dose determined by BG and
type of DM
100-150 (there is a newer
protocol with lower
Not mentioned. Appears
to be < 150
‘‘94% within 3 hours’’
0.5% < 60 (% of
readings?) Not reported with any
? Changes based on present BG and
? Relatively complex
? Dosing based on:
0.3% of readings <60 BG
<60 in 5.4% of patient
? Current BG
? Velocity of glucose change
? Infusion rate
122 ? 17 Once target
0.2% of all BGs < 60 mg/
Dl BG < 60 in 2.9% of
? Uses 3 tables
? Relatively complex
? Initial dose based on BG
Mostly surgical ICU and
CVICU (75% surgical)
135 ? 49 (higher in SICU
and CVICU alone)
1.5% of readings
< 60 mg/dL (lower for
CVICU & SICU alone)
? Changes based on present glucose
and rate of change.
? IV bolus used with changes.
? 6-column method
129 ? 25
2.4% of readings <
Computer-directed algorithm (similar
to column method)
Varied by year and
mg/dL when stable)
90% < 150 mg/dL
in 3 hours
0.6% of readings <50 mg/
dL 2.6% of patients
Implementing Insulin Infusion Protocols / Ahmann and MaynardS45
or best recognized IIPs in the literature. Note that
there is variability in study population, the glucose
targets, hypoglycemia, the time to reach the tar-
get, and the time spent in the target range. Other
practical factors to consider in reviewing the liter-
ature and selecting an IIP design are the complex-
ity of the protocol, the required process steps or
calculations, the evidence for staff acceptance,
and the level of resources supporting the pub-
Structural Differences in Protocols
Protocols that vary by level of insulin sensitivity
generally use column methods with the individual
columns representing different categories of insu-
lin sensitivity, placing the most sensitive category
on the left with the highest level of insulin resist-
ance on the far right. These methods use a multi-
plier to adjust for sensitivity. They are constructed
according to the ‘‘rule of 1500, 1700, or 1800,’’
thereby adjusting for changes in insulin sensitivity
that follow surgery or other changes in physiologic
stress in the acute setting. ‘‘Rate of change’’ is
addressed by shifting to the right if correction of
hyperglycemia is too slow and to the left if the
glucose is dropping too rapidly.
Most institutions using the column/insulin
sensitivity method, implement ‘‘paper’’ orders as
first published by Markovitz.28The same concepts
have been used to develop computer-assisted in-
sulin infusion protocols. One published method is
the Glucommander,27but a number of institutions
Other methods use the present glucose and
change from last glucose to constantly adjust to
any situation.7,21–25They usually involve 2 or 3
steps and often require more calculations by the
nurse. These methods are purported to be more
agile or flexible but there have been no direct
comparisons with the column methods looking at
effectiveness, nursing errors, or hypoglycemic risk.
The ‘‘Yale Protocol’’23,24and the ‘‘Portland Proto-
col’’22are 2 prominent examples of this type of
protocol. Adjustments are defined as units, per-
cent change, or a combination of both.
Limitations of the IIP Literature
There had been few published insulin protocols
aimed at reaching specific glucose goals when the
Leuven surgical ICU experience7was published in
2001. These early publications featured algorithms
that adjusted insulin infusions solely on the basis
of glucose level, and did not take the velocity of
change, direction of change, proximity to glycemic
account. Also, the targeted glucose goals in those
reports were not consistent with the present
standards.29–31Other published protocols featured
glucose-insulin-potassium infusion (GIK) proto-
cols that focused on the amount of insulin admi-
nistered and failed to attain appropriately defined
glucose targets.32,33These publications offer no
real guidance in crafting a modern glycemic tar-
Whereas more than 20 modern IIPs directed at
many of the published protocols represent local
modifications of ones previously published else-
where, and no published, prospective, head-to-
head comparisons of the best-known IIPs are
Several reviews of previous published reports
include comparisons of IIPs with varied areas of
emphasis.51–54The reliability of such comparisons
is limited by the inconsistency in methodology
between studies and the different populations
studied. For example, medical populations are
generally harder to control and are more prone to
hypoglycemia than surgical populations,7,21,23,24,50
and some studies include only patients with dia-
betes.4,5,38In addition, definitions of hypoglycemia
and methods of analyzing glycemic control are
highly variable, making comparisons of IIPs chal-
lenging.39As a result, attempts to compare pub-
lished IIP results without consideration of the
In spite of the aforementioned limitations,
there are several lessons we can learn from the IIP
literature and accumulated clinical experience at a
variety of centers.
Glycemic Targets and Other IIP Features Can Evolve
Revisions of protocol details, including glycemic
targets, often evolve over time. This deliberate
demonstrating safe achievement of higher glyce-
mic targets. The Yale team initially selected a con-
servative glycemic target of 100-139 mg/dL, as
depicted in Table 1.23,24They subsequently low-
staff acceptance by
S46Journal of Hospital Medicine Vol 3 / Issue 5 / Supplement 5 / September/October 2008
ered the target range to 90-119 mg/dL and
increased the initial insulin bolus amount by
40%.50The modified protocol displayed improved
performance and yet retained safety, with only 1
glucose reading < 40 mg/dL in 101 patients over
117 runs of insulin infusion.
The Portland Protocol, used primarily in car-
diac surgery patients, has also evolved over time.
This group has altered the IIP in a number of
ways at least 4 times. These protocols, including
the most recent protocol targeting glucose levels of
70-110 mg/dL, is found at www.portlandprotocol.
Medical and Surgical Patients Are Different
The most convincing evidence for stringent glyce-
mic control evolved from studies of surgical
patients.4,5,7Acknowledging this fact, along with
the greater degree of difficulty in achieving glyce-
mic targets safely in critically ill medical patients,
have led many to endorse higher glycemic targets
for certain populations than others.57Although we
generally favor a uniform glycemic target for a
unit servinga particular
adopting a less stringent glycemic target in medi-
cal ICU settings compared to surgical ICU settings
is reasonable and prudent in many institutional
settings. However, the accompanying challenges
regarding ‘‘boarding’’ patients
nurses between units would also need to be
Local Factors and Implementation Methods Matter
The success or failure of a protocol likely depends
on local factors and implementation methods as
much as it does on the structure of the protocol
itself. IIP development and implementation is a
process that must be approached systematically
and with attention to detail.19Errors in approach
can delay or abort the implementation, or poten-
tially lead to an ineffective or unsafe protocol for
The Yale experience again provides us with a
salient example.58Initial efforts to implement an
IIP failed due to a number of factors: a compli-
cated protocol, insufficient nursing involvement,
and inadequate training and education led to
incomplete buy-in, and nursing concerns over
‘‘hypoglycemia’’ that actually was within the goal
range of the protocol. Successful implementation
was not achieved until the leaders learned from
their mistakes. Nurses and other clinical allies
were involved and educated. Important stake-
holders, who were not included earlier, were now
involved, and front-line
engaged in proactive troubleshooting.
In another example, multisite studies like
VISEP59and Glucontrol9have tried to adapt the
Leuven protocol, only to struggle with excessive
hypoglycemia and an inability to replicate the
tight glycemic control enjoyed by van den Berghe
and colleagues.7,21The Leuven care team augmen-
ted the performance of the IIP by their experience
with the protocol, physician involvement, and
adjustments made by the nursing staff.
Some IIPs Have Lower Hypoglycemia Rates than Others
Recent articles have highlighted the association of
intensive insulin treatment, hypoglycemia, and
mortality in the medical ICU population.60Con-
cerns that excessive hypoglycemia could reduce or
reverse the overall benefits of intensive insulin
therapy has led some to call for moderation of
critical care glycemic targets.61Comparisons of
IIPs52–54,61that include information about the pro-
pensity of the IIP to produce hypoglycemia are
The Leuven IIP has been reported to yield
high rates of hypoglycemia with almost 20% of
patients suffering from severe hypoglycemia (glu-
cose < 40 mg/dL) in some studies.9,21,59By way of
contrast, several different IIP regimens have fre-
quently achieved identical or very similar glycemic
control with less than 5% of the patients experien-
cing severe hypoglycemia.27,50,62Although imple-
mentation factors, severity of illness, and other
population factors play some role, some protocols
have an inherent structural propensity to produce
more hypoglycemia than others. In the case of the
Leuven protocol, there is more of a role for clini-
cian adjustment, and the written protocol itself
does not call for much active adjustment as the
patient enters into the hypoglycemic range.52In
regimens adjust more aggressively in this range
and consistently induce less hypoglycemia.
Successful Methods to Manage the Complexity of an IIP
Many modern IIPs use bolus insulin to expedite
control and adjust the infusion rate based on the
velocity and direction of glucose change, not just
the glucose value.52Insulin resistance is taken
Implementing Insulin Infusion Protocols / Ahmann and Maynard S47
into account in some models, and multiple calcu-
lation steps are required in several reported proto-
The improved automation and control
refinements come at a cost of increased complexity.
Intensive implementation efforts and strong
leadership can overcome some issues, as demon-
strated by the Yale experience, but 2 other strate-
gies have commonly demonstrated success. First,
focused expert glycemic management teams that
directly oversee many aspects of the IIP, or even
assume direct management roles, can be quite
effective,25especially during early implementa-
Automation of calculations and computeriza-
tion is another method to consider, and many
recent reports involve applications of web-based
methods, computerized versus column methods,
method are now available.42,45,46,48,62Computer-
ized protocolsshow significant
would be expected to reduce dosing errors. These
instruments generally present the nurse with a
specific infusion rate after each monitored glucose
and then recommend an interval for the next glu-
cose determination. In direct comparisons, they
tend to perform as well or often better than con-
ventional methods. For example, in the most
recent randomized trial comparing the Glucom-
mander to a paper-based column method in an
ICU, Newton and colleagues found the computer-
ized method reached the goal more rapidly and
reached a lower mean glucose without increasing
the rate of severe hypoglycemia (< 40 mg/dL).62
Computerized methods also facilitate data collec-
tion for analytical purposes.
Computerized systems (both commercial and
home-grown versions) are becoming more com-
mon and appear to hold significant benefits as
long as they are backed by a validated algorithm.
Whereas many institutions are not yet in a posi-
tion to integrate such protocols into their standard
or electronic record systems, we expect the trend
for increased implementation to continue.
ENHANCING THE DESIGN OF YOUR IIP
Once the improvement team has identified and
examined current order sets and protocols in the
context of the literature, we encourage consolida-
tion of institutional insulin infusion orders into a
common basic structure. This basic structure
should be enhanced by incorporating a variety of
elements designed to enhance the reliability of
use and safety of the IIP. These design features are
outlined in Table 3. Randomized trial evidence of
the effectiveness of these design features are
largely lacking, but they are well grounded in
reliability principles and common experience, and
have also been recommended by others.10–13,58
The orders should require a single physician
signature and limited physician choices as the ve-
hicle initiating the nurse-driven protocol. The gly-
cemic target range should be explicitly identified,
and guidance for calling the physician and how to
handle interruptions in nutrition should be em-
bedded in the order set. Frequent monitoring of
glucose levels is necessary for the safe infusion of
insulin. Guidance for how often the monitoring is
required must be explicit and included in the
infusion order set, and standardization of docu-
mentation of the infusion rates and glucose values
is highly desirable. IIPs that adjust based on the
velocity of glucose change and insulin sensitivity
are desirable. Certain elements may be more
appropriate for some institutions than others,
partly based on previous protocols and methods
of practice. For example, the hypoglycemia proto-
col may be embedded or referred to as a separate
standard of care with clear presence in the chart.
The intended timing of conversion from IV to SC
insulin should be included, but the actual method
may be the subject of a separate order set. At
other times, the conversion formula will be part of
the initial intravenous order set.
Ingredients for Insulin Infusion Protocol Orders
h Identifies the glycemic target range
h Includes clear dosing instructions with acceptable calculation requirements for
h Incorporates glucose monitoring expectations
h Easy physician ordering, check box simplicity
h Criteria for calling the physician
h Includes guidance on steps to follow for interruption of nutrition
h States guidelines on when to initiate the infusion and when to stop
h Defines the insulin concentration clearly and consistently
h Considers changing insulin sensitivity as well as the current glucose value and
rate of change in attempting to reach goal and avoid hypoglycemia
h Includes or refers to a standardized hypoglycemia treatment protocol and
h Incorporates guidelines and cautions for transition to subcutaneous insulin
h Ideally adaptable outside of critical care unit—clear definition of locations where
order set is to be used.
S48Journal of Hospital Medicine Vol 3 / Issue 5 / Supplement 5 / September/October 2008
IMPLEMENTATION: ADDRESSING SAFETY ISSUES
The use of insulin infusions comes with several
potential hazards. Many of these potential compli-
cations can be proactively addressed, thereby
minimizing accidental injuries to the patient on
an insulin infusion.
Standardizing Insulin Infusion Preparations and Priming
Varied concentrations or types of insulin for insulin
infusions can lead to serious errors. Insulin infu-
sions should generally be centrally prepared with a
standard concentration of regular insulin in the
pharmacy (usually 1 unit/cc), and the infusion con-
centration should be included in your infusion
order set. Insulin binding to IV tubing can lead to
false elevation of insulin requirements, potentially
followed by serious hypoglycemia. When nurses
change IV tubing or initially set up an insulin drip,
education/instructions on priming new tubing with
a small amount of insulin infusion to saturate the
binding to the polyvinyl chloride tubing should be
incorporated into their routine. Although 50 mL
has often been recommended for priming, a recent
study64found that 20 mL of insulin infusion is
enough to reach the saturation point.
Avoiding Over-Reliance on the Insulin Protocol
Nurse-driven insulin infusion protocols automate
frequent insulin adjustment and reduce unneces-
sary calls to the physician. Although this is gener-
ally a decided advantage, the care team can be
lulled into a sense of false security by the pre-
sence of orders that allow for such adjustment.
Increasing the rate of an insulin infusion without
thoughtful attention to factors that may be playing
a role in this increased requirement (such as
developing sepsis, other medical decompensation,
steroid boluses, or an increase in carbohydrate
intake) can have serious consequences. By the
same token, an unanticipated rapid decrease in
insulin requirement should lead to a reassessment
of the infusion, and an inquiry about cessation of
glucocorticoid therapy or nutrition. Rarely, a phar-
macy or nursing error may induce a pseudo-
change in insulin requirements. The protocol
should lead the nurse to seek advice and alert the
physician to review potential causes of dramatic
changes in insulin requirements, rather than sim-
ply adjusting insulin or nutrition to correct the
present abnormal value.
Interruption of the Insulin Infusion
Interruption of insulin infusions may occur for
many reasons, either intended or unintended. At
times, the doctors or nurses may temporarily stop
the protocol to allow for delivery of blood pro-
ducts or medications when IV access is limited.
Infusions may mistakenly not be restarted, or
deliberate discontinuation may not be adequately
communicated, potentially leading to worsening
hyperglycemia or even the development of ketoa-
cidosis, and other adverse clinical outcomes.
Therefore, the algorithm should have clear orders
for the nurses to contact the ordering physician if
the infusion is stopped for any reason, other than
protocol-driven cessation due to falling blood glu-
Interruption of Nutrition, Field Trips, and Communication
Insulin infusion commonly provides both basal
and nutritional insulin requirements. Interruptions
in nutritional intake are extremely common in the
inpatient setting, with a potential to cause serious
hypoglycemia. Feeding tubes are often pulled out
without warning; enteral nutrition may also need
be halted if high gastric residuals are noted or
during certain diagnostic tests. At times, IV carbo-
nutrition, total parenteral nutrition) may be in-
terrupted as well. In some cases, ‘‘field trips’’ out
of the critical care units to the operating room,
imaging studies, or other hospital locations add
another layer of challenges to managing the IIP.
Staff in these various areas may not be familiar
with the IIP or monitoring standards and techni-
ques, and potentially may not even be aware that
the patient is on an insulin infusion. It is therefore
crucial to anticipate these pitfalls and develop
effective institutional procedures for addressing
them. For example, many institutions use D10 so-
lution to replace the carbohydrate calories that
are lost when tube feedings have to be interrupted
in a gram-per-gram fashion. Patients should be
clearly identified as being on an insulin infusion.
The requirement for consistent glucose monitor-
ing, hypoglycemia recognition and treatment, and
insulin infusion adjustment requires either critical
care nurse care of the patient on the field trip, or
training in the same skills in areas such as endos-
rooms including the preoperative and postopera-
tive care units. In any case, all services should be
Implementing Insulin Infusion Protocols / Ahmann and Maynard S49
involved in crafting solutions that will ensure a
consistent approach to glycemic control as the
patient travels off-unit. Monitoring and treatment
equipment needs to be readily available in all
sites, and hypoglycemia protocols need to be dis-
tributed and supported in all areas.
Preventing and Treating Hypoglycemia
Some hypoglycemia will occur with infusion pro-
tocols, no matter how carefully a protocol is
crafted and how well it is administered. Hypogly-
cemia protocols should therefore be incorporated
directly into an infusion order set. Treatment of
hypoglycemic events with a full 50 mL of D50 so-
lution is equivalent to 25 g of carbohydrate, which
will raise glucose levels in the average patient by
125 mg/dL. Many institutions discourage the over-
correction of hypoglycemic events by encouraging
giving lesser aliquots of D50 based on the degree
Preventing hypoglycemia by recognizing hypo-
glycemia risk factors, proper monitoring, and
anticipating reductions in insulin requirements
from decreasing severity of illness, nutritional
intake, or steroid dosing can also reduce the fre-
quency of hypoglycemic events.
IMPLEMENTATION: EDUCATING AND ENGAGING
NURSING AND PHYSICIAN STAFF
Nursing staff generally bear the brunt of the bur-
den on the front line of implementing intensive
IIPs. Educational efforts for nurses should include
the rationale for intensive insulin therapy and use
ofan IIP. Additionally,
instruction on utilization of the IIP is required.
Properly educated, nursing staff often become the
strongest advocates of the IIP. In addition, they
can frequently provide important input when
situations arise that require troubleshooting. Reg-
ular feedback sessions early in implementation
that address ease of use, clarity of orders, and dif-
ficulties encountered by nurses can be invaluable.
Improvement teams need to provide frequent in-
service training and updates on the IIP selected
after implementation. This is imperative to pro-
mote nursing acceptance and adherence to the IIP
chosen, particularly with consideration for travel-
ing nurses. The importance of nursing champions
to design and carry out this work cannot be over-
stated. Educational programs focusing on the phy-
sician staff can also be very useful, particularly
when focused on high-volume physicians and in-
fluential thought leaders.
IMPLEMENTATION: ADDRESSING COMMON
Steroid boluses are commonly an integral part of
regimens targeting a variety of conditions, such as
transplant rejection, reactive airways disease, cer-
tain infections, cancer, and a variety of autoim-
excursions and rapidly varying insulin require-
ments. Educational efforts and treatment regimens
should address the disproportionate impact that
steroids have on postprandial glycemic excursions.
To minimize the glycemic impact of glucocorti-
coid therapy, a team should investigate promoting
the use of steroid infusions in situations when a
bolus is not absolutely necessary.
can leadto glycemic
Dealing with the Eating Patient and Other Sources of
Carbohydrate-Induced Glycemic Excursions
Glucose levels can be difficult to control in
patients who are eating while on insulin infusion,
because the infusion ‘‘chases’’ the glycemic excur-
sions through frequent adjustments, often with a
late overshoot and inappropriate reduction in
dose. We instead recommend providing bolus
nutritional insulin to cover the expected glycemic
excursion caused by carbohydrate ingestion. Car-
bohydrate counting and using a unit of insulin for
each 10-15 g of carbohydrate consumed can
smooth out the rapid fluctuations in glucose. Gui-
dance for this should be incorporated into the
Transition Off of Insulin Infusion
Rational strategies for dealing with this transition
are covered in detail elsewhere in this supple-
ment.65Guidance for managing this transition
should be integrated into your insulin infusion
and SC order sets. The transition to SC insulin
may represent a separate order set but is some-
times best integrated into the IV insulin infusion
order set itself.
IIPs Outside of the Critical Care Setting
IIPs are most commonly used in the critical care
setting. In some institutions, IV insulin protocols
are safely and effectively employed outside the
S50 Journal of Hospital Medicine Vol 3 / Issue 5 / Supplement 5 / September/October 2008
ICU. Obviously, the number of nurses and other
personnel who must be familiar with such proto-
cols is much higher outside the ICU, and protocol
errors are therefore likely to be somewhat higher.
In addition the nurse-per-patient ratio is usually
lower outside of the critical care setting. As a
result, suggestions for safe implementation of in-
sulin infusion regimens outside of the critical care
c Choose an infusion protocol with a higher glycemic
c Limit the medical and surgical units where this ex-
pertise will be developed.
c Consider simplified infusion protocols but stay
consistent with format.
c Automated or computerized assistance of calcula-
tions may reduce human error and nursing burden.
ASSESSING THE IMPACT OF YOUR EFFORTS:
FOLLOW-UP AND FOLLOW-THROUGH
Monitoring, Recording, and Analyzing Glycemic
Once the IIP is implemented, it is critical that the
impact on glycemic control, hypoglycemia, insulin
use, and other factors be analyzed and used for
improving the IIP and care delivery. Frequent
monitoring of glucose levels is necessary for the
safe infusion of insulin. Guidance for how often
the monitoring is required must be explicit and
included in the infusion order set. Intermittent
auditing for compliance with the frequency of glu-
cose testing and appropriate dose selection is
good practice. Attention should be paid to how
the glucose level is obtained, recorded, and made
available to the health care team in your institu-
tion. All glucose readings should be recorded elec-
tronically for ongoing analyses and retrieval, and
ideally, this could be done in an automated or sin-
gle-step method. Try to eliminate duplication of
effort, such as asking the nurse to record the glu-
cose level and their reaction to it on paper and
again in an electronic format. Your team should
also provide guidance about the potential pro-
blems of using point-of-care glucose testing in
settings with hypotension, sepsis, pressor use, and
other conditions that may impair the accuracy of
capillary glucose readings.
Reports on the time to reach the glycemic tar-
get, glycemic control while on infusion, and the
incidence of hypoglycemia should be reviewed by
the multidisciplinary steering committee. The So-
ciety of Hospital Medicine Glycemic Control Task
Force recommends analysis by patient 2 day and
by patient 2 stay (or insulin infusion run) as pre-
ferred methodologies for analysis of glycemic con-
trol and hypoglycemia rates over the method of
using each individual glucose reading as the unit
of analysis. (The latter tends to under-value the
frequency of hypoglycemia.) Detailed practical
recommendations for analyzing and summarizing
glycemic control data are available elsewhere in
this supplement.18These data should drive deci-
sions on modification of glycemic targets and the
protocol structure. Patients meeting prespecified
criteria should be referred to the improvement
team for review. For example, patients who experi-
ence any glucose readings of ? 40 mg/dL, or who
take more than 12 hours to reach the upper limit
glycemic target should be referred to the team for
a case review.
Assessing Adherence to the Protocol and
Focused audits in the pilot and early implementa-
tion phases should look for nonadherence to the
protocol. Deviations should be evaluated accord-
ing to the patterns identified. For example, varia-
tion in application in some cases is specific for an
individual and in others is characteristic of a spe-
cific group or the whole. Accordingly, this may
point to gaps in education or attitudes about the
importance of this endeavor. Front-line staff may
deviate from the protocol because they find it
ineffective, unsafe, or impractical for certain situa-
tions or specific patients. Many IIPs are the sub-
ject of nursing errors related to the knowledge and
acceptance of the nurse but also the complexity of
the protocol. Appropriate modifications to the
protocol based on these cases can frequently
improve the ease of use and effectiveness of the
protocol. The ongoing review process should iden-
tify issues that must be addressed with permanent
solutions rather than accepting frequent indivi-
dual alterations to meet goals. Revisions require
supplementary education and rapid and wide dis-
monitoring are often most intense in the early
implementation phase, periodic retraining should
continue to achieve optimal results and safety.
Educational tools must consider nursing time
commitments and will often include an interactive
Implementing Insulin Infusion Protocols / Ahmann and Maynard S51
web-based module that gives more flexibility for
trainers and clinical nurses alike.
Insulin infusions are a powerful clinical tool in the
inpatient setting to maintain glycemic control.
Many IIPs have been developed and used success-
fully. The institutional challenge is to select,
modify, and implement the IIP to reduce hyper-
glycemia and improve outcomes without excess
hypoglycemia. In order to accomplish this goal
safely and efficiently, standardized processes and
collaboration between physicians, nurses, and
pharmacists are needed. The keys to minimizing
errors include developing a culture of safety and
cooperation, back-up checks, standardization, au-
tomation, and robust training for all those who
are involved in the care of a patient on an insulin
infusion. Although we encourage standardization
and the use of protocols, providers always need to
consider the unique clinical circumstances and
potential problems presented by each individual
patient. It is important to recognize the many bar-
riers to successful implementation of an IIP, but
strategies exist to overcome these. Finally, remem-
ber that the process does not end with the devel-
opment phase. Continued review is paramount to
success. Note variations in use, analyze them, and
learn from them, in order to continually improve
the process of care.
Address for correspondence and reprint requests: Andrew Ahmann, MD, Har-
old Schnitzer Diabetes Health Center, Oregon Health & Science University,
3181 SW Sam Jackson Park Road, OP05DC, Portland, OR 97239-3098; Tele-
phone: 503-494-1226; Fax: 503-494-4781; E-mail: firstname.lastname@example.org
Received 7 January 2008; revision received 14 August 2008; accepted 14
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