Designing and implementing insulin infusion protocols and order sets

Influential trials and guidelines supporting the value of glucose control in hospital settings, particularly in the intensive care and postoperative settings, has led to the widespread adoption of intravenous infusions of human regular insulin. As groups have attempted to study the outcomes or to explore improved methods for improved glucose control, a number of insulin infusion protocols (IIPs) have been reported and validated. Now, many institutions are attempting to translate this experience into clinical practice in a systematic manner. The intent of this discussion is to highlight the authors' practical view of best practices in development and use of IIPs. As the implementation of IIPs has progressed, it has become apparent that this is not a simple process. It requires a carefully planned, inclusive, and continuous effort striving to attain effective glucose control while avoiding severe hypoglycemia. Whereas there are limitations in the literature comparing the IIPs, we identify design elements and implementation methods that increase the chances for staff acceptance and safe attainment of glycemic goals. Most importantly, this must be a team effort with attention to the numerous potential pitfalls that can disrupt the process and place patients at risk. In many cases, it is best to start more conservatively and methodically intensify the protocol. Continuous assessment of protocol errors, adverse events, staff satisfaction, and outcomes is vital to overall success.