Improving hyperglycemic management in the intensive care unit: Preliminary report of a nurse-driven quality improvement project using a redesigned insulin infusion algorithm

Purpose: The purpose of this study was to assess the feasibility of a nurse-driven effort to improve hyperglycemia management in the intensive care unit (ICU) setting. Methods: The setting was the ICU of a large urban hospital. The program was composed of 3 components: nurses as leaders, a clinical pathway to identify patients in need of hyperglycemia therapy, and implementation of a redesigned insulin infusion algorithm (the Columnar Insulin Dosing Chart). Time to reach a target glucose range of 80 to 110 mg/dL (4.4-6.1 mmol/L) was evaluated. Results: One hundred sixteen ICU nurses were trained in the project. The Columnar Insulin Dosing Chart was applied to 20 patients. The average time required to reach the target blood glucose range was 12.8 hours. Below-target blood glucose levels were 6.9% of all blood glucose levels recorded, but only 0.9% were below 60 mg/dL (3.3 mmol/L). There was no sustained hypoglycemia, and no persistent clinical findings attributable to hypoglycemia were noted. Barriers to implementing the project included an increased nursing workload, the need for more finger-stick blood glucose monitors, and the need to acquire new finger-lancing devices that allowed for shallower skin puncture and increased patient comfort. Conclusions: Tighter glycemic control goals can be attained in a busy ICU by a nurse-led team using a pathway for identifying and treating hyperglycemia, clear decision support tools, and adequate nurse education. The novel chart-based insulin infusion algorithm chosen as the standard for this pilot was an effective tool for reducing the blood glucose to target range with no clinically significant hypoglycemia.