Despite multiple revisions of an IV insulin paper protocol, analysis of data from usage of the paper protocol at WMC shows that in terms of achieving normoglycemia while minimizing hypoglycemia, results were suboptimal. Therefore, through a systematical implementation plan, monitoring of patient blood glucose levels was switched from using a paper IV insulin protocol to a computerized glucose management system.
By comparing blood glucose levels using the paper protocol to that of the computerized system, it was determined, that overall, the computerized glucose management system resulted in more rapid and tighter glucose control than the traditional paper protocol. Specifically, a substantial increase in the time spent within the target blood glucose concentration range, as well as a decrease in the prevalence of severe hypoglycemia (BG < 40 mg/dL), clinical hypoglycemia (BG < 70 mg/dL), and hyperglycemia (BG > 180 mg/dL), was witnessed in the first five months after implementation of the computerized glucose management system.
implementation of the paper protocol resulted in errors in blood glucose level readings and in increases in hypoglycemic events. Further investigation uncovered the multiple causes of these errors. Omitting the insulin bolus and not changing the rate of the insulin infusion when instructed to do so in the protocol accounted for 55% of all errors. Other error types included incorrect change in the IV insulin rate, either too high or too low, and incorrect insulin bolus dose administered, either too high or too low.
Third Protocol Change is the Charm
First Revision of Paper Protocol
64.7% of BG readings were in target range; 1.4% were below 70 mg/dL; significant unjustified nurse deviation
Second Revision of Paper Protocol
63.6% of BG readings were in target range; 6.9% were below 70 mg/dL; significant unjustified nurse deviation
Third Attempt: Computerized System
86.1% of BG readings were in target range; 0.8% were below 70 mg/dL; reduced nurse deviation
Author(s): Michael C. Magee
Location: Wyoming Medical Center, Casper, WY
Source: Journal of Visualized Experiments, 2012; (64): 3705.
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