A guideline for the use of variable rate intravenous insulin infusion in medical inpatients

[Hospital diabetes management (Update 2023)]

This position statement presents the recommendations of the Austrian Diabetes Association for diabetes management of adult patients during inpatient stay. It is based on the current evidence with respect to blood glucose targets, insulin therapy and treatment with oral/injectable antidiabetic drugs during inpatient hospitalization. Additionally, special circumstances such as intravenous insulin therapy, concomitant therapy with glucocorticoids and use of diabetes technology during hospitalization are discussed.

The management of diabetic ketoacidosis in adults-An updated guideline from the Joint British Diabetes Society for Inpatient Care

This article summarises the Joint British Diabetes Societies for Inpatient Care guidelines on the management of ketoacidosis; available at https://abcd.care/resource/management-diabetic-ketoacidosis-dka-adults. The document explicitly states that when a person aged 16-18 is under the care of the paediatric team, then the paediatric guideline should be used, and if they are cared for by an adult team, then this guideline should be used. The guideline takes into account new evidence on the use of the previous version of this document, particularly the high prevalence of hypoglycaemia and hypokalaemia, and recommends that when the glucose concentration drops below 14 mmol/L, that de-escalating the insulin infusion rate from 0.1 to 0.05 units/kg/h should be considered. Furthermore, a section has been added to address the recognition that use of sodium glucose co-transporter 2 inhibitors is associated with an increased risk of euglycaemic ketoacidosis. The management of ketoacidosis in people with end-stage renal failure or on dialysis is also mentioned. Finally, the algorithms to illustrate the guideline have been updated.

Using video reflexive ethnography to explore the use of variable rate intravenous insulin infusions

Background

The use of variable rate intravenous insulin infusion (VRIII) is a complex process that has consistently been implicated in reports of error and consequent harm. Investment in patient safety has focused mainly on learning from errors, though this has yet to be proved to reduce error rates. The Resilient Health Care approach advocates learning from everyday practices. Video reflexive ethnography (VRE) is an innovative methodology used to capture everyday practices, reflect on and thereby improve these. This study set out to explore the use of VRIIIs by utilising the VRE methodology.

Methods

This study was conducted in a Vascular Surgery Unit. VRE methodology was used to collect qualitative data that involved videoing healthcare practitioners caring for patients treated with VRIII and discussing the resulting clips with participants in reflexive meetings. Transcripts of these were subjected to thematic analysis. Quantitative data (e.g. blood glucose measurements) were collected from electronic patient records in order to contextualise the outcomes of the video-observed tasks.

Results

The use of VRE in conjunction with quantitative data revealed that context-dependent adaptations (seeking verbal orders to treat hypoglycaemia) and standardised practices (using VRIII guidelines) were strategies used in everyday work. Reflexive meetings highlighted the challenges faced while using VRIII, which were mainly related to lack of clinical knowledge, e.g. prescribing/continuing long-acting insulin analogues alongside the VRIII, and problems with organisational infrastructure, i.e. the wireless blood glucose meter results sometimes not updating on the electronic system. Reflexive meetings also enabled participants to share the meanings of the reality surrounding them and encouraged them to suggest solutions tailored to their work, for example face-to-face, VRIII-focused training.

Conclusions

VRE deepened understanding of VRIII by shedding light on its essential tasks and the challenges and adaptations entailed by its use. Future research might focus on collecting data across various units and hospitals to develop a full picture of the use of VRIIIs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07883-w.

Managing hyperglycaemia during antenatal steroid administration, labour and birth in pregnant women with diabetes - an updated guideline from the Joint British Diabetes Society for Inpatient Care

This article summarises the Joint British Diabetes Societies for Inpatient Care guidelines on the management of glycaemia in pregnant women with diabetes on obstetric wards and delivery units, Joint British Diabetes Societies (JBDS) for Inpatient Care Group, ABCD (Diabetes Care) Ltd. The updated guideline offers two approaches - the traditional approach with tight glycaemic targets (4.0-7.0 mmol/L) and an updated pragmatic approach (5.0-8.0 mmol/L) to reduce the risk of maternal hypoglycaemia whilst maintaining safe glycaemia. This is particularly relevant for women with type 1 diabetes who are increasingly using Continuous Glucose Monitoring (CGM) and Continuous Subcutaneous Insulin Infusion (CSII) during pregnancy. All women with diabetes should have a documented delivery plan agreed during antenatal clinic appointments. Hyperglycaemia following steroid administration can be managed either by increasing basal and prandial insulin doses, typically by 50% to 80%, or by adding a variable rate of intravenous insulin infusion (VRIII). Glucose levels, either capillary blood glucose or CGM glucose levels, should be measured at least hourly from the onset of established labour, artificial rupture of membranes or admission for elective caesarean section. If intrapartum glucose levels are higher than 7.0 or 8.0 mmol/L on two consecutive occasions, VRIII is recommended. Hourly capillary blood glucose rather than CGM glucose measurements should be used to adjust VRIII. The recommended substrate fluid to be administered alongside a VRIII is 0.9% sodium chloride solution with 5% glucose and 0.15% potassium chloride (KCl) (20 mmol/L) or 0.3% KCl (40 mmol/L) at 50 ml/hr. Both the VRIII and CSII rates should be reduced by at least 50% after delivery.

Modelling the use of variable rate intravenous insulin infusions in hospitals by comparing Work as Done with Work as Imagined

BACKGROUND

Variable rate intravenous insulin infusions (VRIIIs) are widely used to treat elevated blood glucose (BG) in adult inpatients who are severely ill and/or will miss more than one meal. VRIIIs can cause serious harm to the patient if used incorrectly. Recent safety initiatives have embraced the Resilient Health Care (RHC) approach to safety by understanding how VRIIIs are expected to be used (Work as Imagined, 'WAI') and how it is actually used in everyday clinical care (Work as Done, 'WAD').

OBJECTIVES

To systematically compare WAI and WAD and analyse adaptations used in situ to develop a model explaining VRIII use.

METHODS

A qualitative observational study video-recording healthcare practitioners using VRIII. The video data were transcribed and inductively coded to develop a hierarchical task analysis (HTA) to represent WAD. This HTA was compared with a HTA previously developed to represent WAI. The comparison output was used to develop a model of VRIII use.

RESULTS

While many of the tasks in the WAD HTA were aligned with the tasks presented in the WAI HTA, some important ones did not. When misalignment was observed, permanent adaptations (e.g. signing as a witness for a changed VRIII's rate without independently verifying whether the new rate was appropriate) and temporary workarounds (e.g. not administering intermediate-acting insulin analogues although the intermediate-acting insulin prescription was not suspended) were the most frequently observed adaptations. The comparison between WAI and WAD assisted in developing a model of VRIII use. The model shed light on strategies used to imagine everyday work (e.g. incident reports, VRIII guidelines), how everyday work was accomplished (e.g. context-dependent adaptations) and how these contributed to both successful and unsuccessful outcomes.

CONCLUSIONS

This study provided in-depth understanding of the tasks required while using VRIIIs, and responses and adaptations needed to achieve safer care in a complex environment.

A prospective randomized trial comparing computerized columnar insulin dosing chart (the Atlanta protocol) versus the joint British diabetes societies for inpatient care protocol in management of hyperglycemia in patients with acute coronary syndrome admitted to cardiac care unit in Alexandria, Egypt

BACKGROUND

Hyperglycemia in acute coronary syndrome (ACS) is linked to raised morbidity and mortality. Insulin administration using insulin infusion protocols (IIP) is the preferred strategy to control hyperglycemia in critically ill patients. To date, no specific IIP has been identified as the most efficient for achieving glycemic control.

AIM

to compare glycemic achievements (safety) (primary objective), and coronary and other clinical outcomes (efficacy) (secondary objective) by hyperglycemia management in Cardiac Care Unit (CCU) using computerized Atlanta Protocol (Group (I)) versus paper-based Joint British Diabetes Societies (JBDS) For Inpatient Care Protocol (Group (II)).

PATIENTS AND METHODS

The study was done on 100 ACS patients admitted to Alexandria Main University hospital CCU with RBG >180 mg/dL. They were randomized into the 2 groups in a 1:1 ratio. CBG was measured hourly for 72 hours and was managed by IV insulin infusion.

RESULTS

Group (I) showed statistically significant less mean time for target BG achievement (3.52 ± 1.53hours), lower incidence of Level 1 hypoglycemia (2%) than Group (II) (4.76 ± 2.33 hours, 22%, p = 0.013, 0.002 respectively) and statistically significant less mean number of episodes above the glycemic target after its achievement than Group (II) (p < 0.001). Regarding Level 2 hypoglycemia the difference was not significant statistically.

CONCLUSION

Both protocols successfully maintained target BG level with low incidence of clinically significant hypoglycemia, however, the computerized Atlanta protocol achieved better glycemic outcomes. We recommend the use of the computerized Atlanta protocol in CCU rather than JBDS for Inpatient Care Protocol whenever this is feasible.

Detailed analysis of 'work as imagined' in the use of intravenous insulin infusions in a hospital: a hierarchical task analysis

OBJECTIVE

Variable rate intravenous insulin infusions (VRIII) is a high-risk medication that has a potential to cause significant patient harm if used in error. Complex preparation of VRIII in clinical areas and the need for frequent monitoring and adjustment increase the complexity of using VRIII. An emerging approach, called Resilient Healthcare, proposes understanding complexity of work by exploring how work is assumed to be done and compare it with everyday work. This study aimed to explore how VRIII is perceived to be used by healthcare practitioners, focusing on one aspect of Resilient Healthcare: understanding how work is assumed to be done, using a method called hierarchical task analysis (HTA).

DESIGN

A qualitative study using document analysis and focus groups.

SETTING

A vascular surgery unit in an acute National Health Service teaching hospital in the UK.

PARTICIPANTS

Stakeholders/users in different professional roles involved in the process of using VRIII.

RESULTS

The HTA showed the complexity of using VRIII and highlighted more than 115 steps required to treat elevated blood glucose. The process of producing hospital-specific guidelines was iterative. Careful consideration was taken to coordinate the development and implementation of guidelines. Documents provided detailed clinical instructions related to the use of VRIII but practitioners selectively used them, often in deference to senior colleagues. Intentional adaptations, for example, proactively asking for a VRIII prescription occurred and were acknowledged as part of providing individualised patient care.

CONCLUSION

Using VRIII to treat elevated blood glucose is a complex but necessary process mediated by a range of factors such as organisational influences. Adaptive strategies to mitigate errors were common and future research can build on insights from this study to develop a broader understanding of how VRIII is used and to understand how adaptations are made in relation to the use of VRIII.

Diabetes at the front door. A guideline for dealing with glucose related emergencies at the time of acute hospital admission from the Joint British Diabetes Society (JBDS) for Inpatient Care Group

People with diabetes account for nearly one-fifth of all inpatients in English and Welsh hospitals; of these, up to 90% are admitted as an emergency. Most are admitted for a reason other than diabetes with only 8% requiring admission for a diabetes-specific cause. Healthcare professionals working in emergency departments experience numerous clinical challenges, notwithstanding the need to know whether each individual with diabetes requires urgent admission. This document has been developed and written by experts in the field, and reviewed by the parent organizations of the Joint British Diabetes Societies for Inpatient Care-Diabetes UK, the Diabetes Inpatient Specialist Nurse Group and the Association of British Clinical Diabetologists. The document aims to support staff working in emergency departments and elsewhere by offering practical advice and tools for effective, appropriate and safe triage. Each section relates to the commonest diabetic specific emergencies and algorithms can be printed off to enable ease of access and use.

Recent advances in diabetes treatments and their perioperative implications

PURPOSE OF REVIEW

The implications for perioperative management of new oral antihyperglycemic medications and new insulin treatment technologies are reviewed.

RECENT FINDINGS

The preoperative period represents an opportunity to optimize glycemic control and potentially to reduce adverse outcomes. There is now general consensus that the optimal blood glucose target for hospitalized patients is approximately 106-180 mg/dl (6-10 mmol/l). Recommendations for the management of antihyperglycemic medications vary among national guidelines. It may not be necessary to cease all antihyperglycemic agents prior to surgery. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are associated with higher rates of ketoacidosis especially in acutely unwell and postsurgical patients. The clinical practice implications of new insulin formulations, and new systems for insulin delivery, are not clear. The optimal perioperative management of these will vary depending on local institutional factors such as staff skills and existing clinical practices. Improved hospital care delivery standards, quality assurance, process improvements, consistency in clinical practice, and coordinated multidisciplinary teamwork should be a major focus for improving outcomes of perioperative patients with diabetes.

SUMMARY

Sulfonylureas and SGLT2i should be ceased before moderate or major surgery. Other oral antihyperglycemic therapies may be continued or ceased. Complex patients and/or new therapies require specialized multidisciplinary management.

Insulin therapy in organ donation and transplantation

Hyperglycaemia is common in hospitalized individuals, and is often caused by physiological stress associated with critical illness or major surgery. Insulin therapy is an established treatment for hyperglycaemia and acute hyperkalaemia, and has also been used for myocardial dysfunction resistant to inotropic support. Insulin is commonly used in both organ donors and transplant recipients for hyperglycaemia, but the underlying knowledge base supporting its use remains limited. Insulin therapy plays an important yet poorly understood role in both organ donation and transplantation. Tight glycaemic control has been extensively studied in critical care over the past 15 years; however, this has not yet translated into the field of transplantation, where patients are more unwell and where improved outcomes remain an ongoing challenge. Insulin therapy and optimization of glycaemic control represent important areas for future hypothesis-driven research into organ donation and transplantation, such as amelioration of ischaemia-reperfusion injury, rejection and infection.

Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: review of acute decompensated diabetes in adult patients

Diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome (HHS) are life threatening complications that occur in patients with diabetes. In addition to timely identification of the precipitating cause, the first step in acute management of these disorders includes aggressive administration of intravenous fluids with appropriate replacement of electrolytes (primarily potassium). In patients with diabetic ketoacidosis, this is always followed by administration of insulin, usually via an intravenous insulin infusion that is continued until resolution of ketonemia, but potentially via the subcutaneous route in mild cases. Careful monitoring by experienced physicians is needed during treatment for diabetic ketoacidosis and HHS. Common pitfalls in management include premature termination of intravenous insulin therapy and insufficient timing or dosing of subcutaneous insulin before discontinuation of intravenous insulin. This review covers recommendations for acute management of diabetic ketoacidosis and HHS, the complications associated with these disorders, and methods for preventing recurrence. It also discusses why many patients who present with these disorders are at high risk for hospital readmissions, early morbidity, and mortality well beyond the acute presentation.

[Hospital diabetes management (Update 2019)]

This position statement presents the recommendations of the Austrian Diabetes Association for diabetes management of adult patients during inpatient stay. It is based on the current evidence with respect to blood glucose targets, insulin therapy and treatment with oral antidiabetic drugs during inpatient hospitalization. Additionally, special circumstances such as intravenous insulin therapy, concomitant therapy with glucocorticoids and use of diabetes technology during hospitalization are discussed.

Use of an educational, audiovisual podcast to maximise safety with variable rate intravenous insulin infusions

Variable rate intravenous insulin infusions (VRIII) are used to maintain stable blood glucose in hospitalised patients with diabetes who are unable to eat or have a severe illness where good glycaemic control is paramount. With VRIII it is important to prescribe an adequate substrate to avoid hypoglycaemia and maintain electrolyte balance. Traditionally the substrate would have been varied to achieve this; current guidelines advise varying the infusion rate rather than the type of substrate. The local hospital Trust updated their VRIII prescription chart to reflect the Joint British Diabetes Societies’ suggestions for inpatient care in October 2014. A local audit in January 2015 highlighted that 48% of patients on VRIII were prescribed the correct fluid as per the guideline. A questionnaire to assess prescriber knowledge regarding VRIII showed 40.4% of prescribers selected appropriate fluid for a patient with normal renal function and 11.5% of prescribers selected appropriate fluid for a patient with renal failure. An educational podcast was devised to explain the rationale behind appropriate fluid prescription with VRIII; this was shown to prescribers. Following the podcast, 75.8% of prescribers selected appropriate fluids for normal renal function and 54.5% for renal failure. Questionnaires were completed to assess prescriber knowledge prepodcast and postpodcast. Following the podcast, there was a significant increase in questionnaire scores, indicating improved prescriber knowledge surrounding VRIII. A reaudit of prescriptions for VRIII showed improvement in practice, where 63% of patients on VRIII were prescribed correct fluids. The use of a simple audiovisual podcast on VRIII led to a significant improvement in prescriber knowledge. Podcasts are an ideal medium to raise awareness around safety issues, including safe prescription of insulin. Further work will include the follow-up of participants to evaluate sustained knowledge and improvements of prescriptions in practice, with the overall aim of improving patient safety.