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A Computerized Insulin Infusion Titration Protocol Improves Glucose Control With Less Hypoglycemia Compared to a Manual Titration Protocol in a Trauma Intensive Care Unit

Marcus J. Dortch, PharmD^*, Nathan T. Mowery, MD, Asli Ozdas, PhD, Lesly Dossett, MD, Hanqing Cao, PhD, Bryan Collier, DO, Gwen Holder, RN, MSN, Randolph A. Miller, MD and Addison K. May, MD

From the ^* Department of Pharmaceutical Services, Division of Trauma and Surgical Critical Care, Department of Biomedical Informatics, and Systems Support Services, Vanderbilt University Medical Center, Nashville, Tennessee

Correspondence: Marcus J. Dortch, PharmD, Department of Pharmaceutical Services, Vanderbilt University Medical Center, 1211 22nd Ave S, VUH B101, Nashville, TN 37232. Electronic mail may be sent to marcus.dortch{at}vanderbilt.edu.

Background: Previous studies reflect reduced morbidity and mortality with intensive blood glucose control in critically ill patients. Unfortunately, implementation of such protocols has proved challenging. This study evaluated the degree of glucose control using manual paper-based vs computer-based insulin protocols in a trauma intensive care unit. Methods: Of 1455 trauma admissions from May 31 to December 31, 2005, a cohort of 552 critically ill patients met study entry criteria. The patients received intensive blood glucose management with IV insulin infusions. Using Fisher's exact test, the authors compared patients managed with a computerized protocol vs a paper-based insulin protocol with respect to the portion of glucose values in a target range of 80–110 mg/dL, the incidence of hyperglycemia (150 mg/dL), and the incidence of hypoglycemia (40 mg/dL). Results: Three hundred nine patients were managed with a manual paper-based protocol and 243 were managed with a computerized protocol. The total number of blood glucose values across both groups was 21,178. Mean admission glucose was higher in the computer-based protocol group (170 vs 152 mg/dL; p < .001, t-test). Despite this finding by Fisher's exact test, glucose control was superior in the computerized group; a higher portion of glucose values was in range 80–110 mg/dL (41.8% vs 34.0%; p < .001), less hyperglycemia occurred (12.8% vs 15.1%; p < .001), and less hypoglycemia occurred (0.2% vs 0.5%; p < .001). Conclusions: A computerized insulin titration protocol improves glucose control by (1) increasing the percentage of glucose values in range, (2) reducing hyperglycemia, and (3) reducing severe hypoglycemia.

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