Purpose:
Intravenous (IV) insulin has been shown to be an effective way to achieve tight control of blood glucose in hospital. Managing IV insulin is a labor-intensive task for nurses and is generally done in intensive-care units (ICU) with high nurse-to-patient ratios, 1:1 or 1:2. Many patients with severe hyperglycemia on intermediate-care units could benefit, as well, from tight control of blood glucose. We wanted to have intermediate-care nurses, with unit ratios of 1 to 5 or 6, to manage IV insulin.
Significance:
Evidence reveals that high blood glucose is a risk factor for poor clinical outcomes. Studies also show that tight glycemic control in hospital improves mortality and morbidity and reduces costs. The American Association of Clinical Endocrinologists and the American Diabetes Association in 2006 offered guidance for treating high blood glucose levels in all hospital patients. One recommendation was to implement structured protocols for aggressive control of blood glucose.
Background/Design:
Evidence reveals that high blood glucose is a risk factor for poor clinical outcomes. Studies also show that tight glycemic control in hospital improves mortality and morbidity and reduces costs. The American Association of Clinical Endocrinologists and the American Diabetes Association in 2006 offered guidance for treating high blood glucose levels in all hospital patients. One recommendation was to implement structured protocols for aggressive control of blood glucose.
Methods:
After observation of effectiveness of a novel approach to IV insulin in ICUs, the Diabetes Clinical Nurse Specialist (CNS) and a general medical Nurse Manager (NM) spearheaded a trial of the new IV insulin nomogram for 3 months on 2 intermediate-care units. The IV insulin nomogram would require not only hourly blood glucose measurements but also various calculations. In the educational sessions, the CNS and NM introduced an audit tool and staff feedback mechanism.
Findings:
The 3-month project ended with 22 patients who had 275 correct hourly rate calculations out of a possible 276.
Conclusions:
The nursing staff found the project challenging and satisfying. Audit results indicated that the nomogram could be used effectively on units with a 1:5 or 1:6 staffing ratio.
Implications for Practice:
With the success associated with the 3-month project, we expanded to other adult units, and the CNS developed teaching guidelines. Nurses on other units have easily mastered the nomogram calculations, although some have voiced resistance to hourly blood glucose checks. Our successful experience with IV insulin on non-ICU units shows that patients with severe hyperglycemia can be managed by staff nurses on intermediate-care units and can reap the benefits of tight control of blood glucose in hospital.