We all know the benefits of tight glycemic control, especially in critically ill patients—fewer infections, less renal failure, fewer transfusions, and short hospital stays—to name a few. And, of course, the best method for achieving tight control is a continuous insulin infusion. Unfortunately, in most hospitals, the only units where a patient could receive such an infusion have been critical-care units. But that’s begun to change.
In 2003, more than 10 organizations, including the American College of Endocrinology, set standards identifying target blood glucose levels for both critical-care and non-critical-care patients, treatment methods, and recommendations for a multidisciplinary approach to manage inpatient hyperglycemia.
At my facility, studies showed that patients who were candidates for transfer to a less acute level of care were experiencing longer stays in the intensive care unit (ICU), solely because they needed insulin infusions. That led to a decision to make all adult medical-surgical nursing units able to manage patients receiving continuous insulin infusion therapy. The insulin infusion protocol (IIP) already being used in the ICU, the Beckett protocol, would now be used in all units.
Using the Beckett protocol
What sets the Beckett protocol apart from other protocols is its dosing plan. The Beckett IIP incorporates an engineering control method known as the proportional-integrative method. Most protocols use a proportional insulin dosing plan—simply put, the number of insulin units is a proportional response to the measurement of the blood glucose level. The Beckett IIP adds a second component, the integral or basal insulin dose, which provides cumulative hourly adjustments. The combined proportional and cumulative integral doses then determine the total insulin dose. The result is a gradual decrease in blood glucose level without drastic increases and decreases in insulin dosage associated with other insulin infusion protocols.
Implementing the plan
As a first step to making all units capable of providing continuous insulin infusions, a team made up of nurses and a physician created a plan that identified the need for staff education, staffing and bed placement adjustments, and medical and surgical collaboration during the implementation. Early in the planning phase, the team recognized that bed placement would be key to the success of the implementation, and we decided that the first two nursing units to complete the educational component would be a general medical unit and a step-down cardiac surgical/general surgical unit. With these two units available from the beginning, a patient needing continuous insulin infusion therapy outside of the ICU could be placed on a nursing unit that could handle the therapy, regardless of the physician service. In October 2004, we started implementing the insulin infusion protocol for house-wide use.
We began with staff education, conducting educational in-services during staff meetings. These in-services focused on a review of the benefits of glycemic control for both critical and non-critical-care patients, insulin infusion orders and flowsheets, and case scenarios that involved calculating infusion rates. According to the staff, the review of the benefits of glycemic control was the key to obtaining staff acceptance.
After completing staff education, each nursing unit received a 2-week period of managing patients on the IIP before the next nursing unit began its implementation. By diverting patients to those nursing units that had completed the staff education, the Bed Placement Coordinator provided staff nurses the opportunity to gain experience with this new therapy while maintaining patient safety.
Nurse-managers agreed that staffing ratios would need to be adjusted when caring for a patient on the IIP; however, the exact degree of adjustment was unknown. During the implementation period, a conservative approach to staffing ratios—specifically, three patients to one nurse—was instituted. This allowed the Nursing Department to learn the impact the IIP would have on the workload of the nursing unit. During the implementation process, staff members were encouraged to give feedback on workload and staffing assignments that could be used to develop staffing guidelines.
Collaboration was another key to our implementation. As the inpatient units began using the IIP, the ICU staff served as an invaluable resource. When a patient was placed on the IIP, the charge nurse on the general medical-surgical unit notified the ICU charge nurse, who in turn would designate one ICU nurse per shift to serve as a resource. The ICU nurse was available for any questions or concerns about the IIP or patient management. Every 24 hours, the need for the resource was re-evaluated. The collaboration also extended to me as the ICU Educator who conducted the educational in-services.
I reviewed the dosage calculation flowsheet for the previous 24 hours and provided feedback to staff. This interaction also allowed me to receive feedback from staff nurses regarding their implementation process, difficulties encountered, and creative solutions they developed to address workflow issues with the protocol. This feedback was used to modify future educational sessions to make the implementation process easier for each subsequent nursing unit.
In February 2005, we completed our house-wide implementation of the Beckett IIP. The Beckett IIP was being used on all adult medical-surgical and step-down nursing units, including the operating room, the preoperative holding areas, and the postanesthesia care unit.
Learning about workflow
Despite the extensive plan and timeline for the implementation, we encountered—and corrected—a couple of workflow issues.
When the house-wide use of the IIP was proposed, concerns were raised about the number of bedside glucose meters on the units. A recommendation to increase the number on each nursing unit was rejected because of the uncertainty about how often the IIP would be used and how long a patient would be receiving therapy.
As a compromise, the laboratory purchased meters that nursing units could use as needed. If a unit had several patients receiving insulin infusion therapy or if a unit had a patient in isolation, the laboratory would provide additional meters. For a patient having same-day surgery, a nurse in the preoperative area would obtain a meter from the laboratory, which would remain with the patient through surgery and the recovery period. If the patient was admitted to an inpatient unit after surgery, the meter would be returned to the laboratory, and the nursing staff would use the unit’s meters.
One of our goals for the new protocol was a 1-hour turnaround from the time an order was written until the time the infusion started. When staff reported delays of up to 2 hours before receiving infusions, the team discussed the issue with the pharmacy staff and initiated these changes:
• All insulin infusion orders would be scanned to pharmacy as “STAT.”
• If an infusion didn’t arrive within 30 minutes, the nursing staff would contact the pharmacy to check on the status.
• Every day, the pharmacy would prepare five additional insulin infusions that could be dispensed, as needed.
Accepting the protocol
Most physicians accepted the new protocol. But some refused to use it, and others expressed concern about the increased workload it placed on the nursing staff.
To address the problem of outright refusal, the team enlisted physician champions to promote the IIP. Dr. Beckett and these champions provided a seminar on the benefits of glycemic control as it pertained to the practice specialties of the physicians refusing to use the IIP. As information on the beneficial effects of house-wide IIP use was collected, we shared it with the physician champions, who in turn shared it with the physicians refusing to use the protocol.
The nurses themselves have adapted to using the IIP on the general medical-surgical and step-down areas. How the individual units manage the increased workload varies from unit to unit. The staffing plan used by a general medical unit recommends nurse:patient ratios of 1:3 for days, 1:4 for evenings, and 1:5 for nights. Another nursing unit incorporates the overall staffing ratio and number of patients receiving insulin infusion therapy into its staffing plan. When the staffing ratio is 1:4, with several patients receiving insulin infusion therapy, this unit adds one nurse who’s solely responsible for managing the insulin infusions. This “IIP nurse” can then assist other nurses, as necessary.
When discussing the protocol with patients and families, nurses used phrases such as “best practice” and “decreased risk of infection.” These phrases conveyed to patients and families our goal of providing the best possible care.
Work in progress
Since the implementation, the team has made many changes to the Beckett IIP and the flowsheets. Two of the most significant changes were establishing a more aggressive reduction in a patient’s serum glucose level when it’s more than 400 mg/dl and establishing a more rapid reduction of the insulin dose when a patient’s glucose level is less than 90 mg/dl.
In an effort to control transient increases in glucose levels after meals, the team added a meal-time dose of insulin aspart (NovoLog) subQ to the protocol. The dosage calculation is based on the amount of carbohydrates consumed and the current basal rate of the continuous insulin infusion.
Education is ongoing. When changes were made to the protocol, each nursing unit received a poster stating the changes and providing rationales. Also, for the past 2 years, the IIP has been included as a learning station at both the critical care and general medical-surgical competency validation sessions.
House-wide use of the IIP has resulted in outcome improvements in several key areas:
• The time to target range (serum glucose level of 80 to 130 mg/dl) has dropped by 66% from 18 hours to 6 hours.
• The total time spent in the target range increased to more than 49%.
• The occurrence of significant hypoglycemia (a glucose level below 70 mg/dl requiring treatment with 50% dextrose) is less than 1.5%.
As you may know, the American College of Endocrinology has two distinct upper limits for blood glucose levels. The level for critical-care patients is 110 mg/dl; the level for non-critical-care patients is 180 mg/dl. The Beckett IIP continues to use its original upper limit of 130 mg/dl for two reasons: to promote staff acceptance of using the protocol outside the ICU while limiting the risk of hypoglycemia associated with tighter glycemic control and to promote patient safety by using only one standardized protocol for all adult patient populations.
The protocol is gaining acceptance. About 80 patients a month receive continuous insulin infusions, and physicians and nurses like the comprehensive approach of the protocol. Because it includes instructions for insulin dosing and special actions for managing the patient and the infusion if hypoglycemia or a sudden change in glucose intake occurs, nurses can act immediately without contacting a physician.
The implementation plan for the Beckett IIP has been a success. In 4 months, all adult inpatient nursing areas and perioperative areas finished the educational and patient-management components and could care for patients receiving insulin infusion therapy. Plus, the institution could prove that continuous insulin infusions can be safely administered outside of the ICU.
American College of Endocrinology. Position statement on inpatient diabetes and metabolic control. Endocr Prac. 2004;10(1):77-82.
Clement S, Braithwaite SS, Magee MF, Ahmann A, et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27(2):553-591.
Krinsley JS. Effect of an intensive glucose management protocol on the mortality of critically ill adult patients. Mayo Clin Proc. 2005;79:992-1000.
Van den Berghe G, Wouters S, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001;345:1359-1367.
Michelle M. Jonas, RN, MA, CCRN-CSC, is an ICU Educator at St. Luke’s Hospital in Cedar Rapids, Iowa.