insulin drip protocols

allele, LPN · Aug 5, 2005

We use a protocol that I'm TOLD was based on the Portland Protocol (I'll post the link below).........but looking at this Portland Protocol, ours looks NOTHING like this!! I think the committee may have started with the Portland Protocol as a basis, but really gave it a good tweaking. I guess I'm not sure what you mean by your author doesn't really address hypoglycemia? It doesn't suggest shutting off the gtt and giving D50, rechecking CBG every 1/2 hour? With ours, we aim to keep CBG's under 150, if the patient goes below 100 we shut down the gtt and check CBG every 1/2 hour until they have two consecutive CBG's going up. If they go below 75 we give 1/2 amp of D50 and check CBG's every 1/2 hour until they have two consecutive CBG's going up. After that, we go back to checking every hour until the CBG is greater than 130, then restart the gtt at 1/2 the previous rate. There's a lot more to the protocol, but unfortunately I have no way to send it. Good luck!! :)

http://www.providence.org/resources/oregon/PDFs/Protocol80120.pdf#search='portland%20protocol,%20insulin%20drip'

GenaRN · Aug 8, 2005

Does anyone out there have any experience with insulin drip protocols? Our organization is instituting one and it is looking problematic in that the issue of hypoglycemia and it's risks have not been fully appreciated by the authors of this protocol.
I would appreciate some opinions you all may have.

The facility where I work has a fairly aggressive one for critical care and the goal is BS 80-120, with hourly titrations and boluses. I haven't had any problems with hypoglycemia using it, but like I said, it's really closely monitored. I wouldn't want to use it on the floor, and we don't at our facility.

Mili · Aug 8, 2005

We have a really great protocol. If you want to email me, I will send it to you.

brutuss7 · Aug 8, 2005

The facility where I work has a fairly aggressive one for critical care and the goal is BS 80-120, with hourly titrations and boluses. I haven't had any problems with hypoglycemia using it, but like I said, it's really closely monitored. I wouldn't want to use it on the floor, and we don't at our facility.

We are using on the floors. How is your protocol closely monitored? any chance i can get a copy of your protocol?

brutuss7 · Aug 8, 2005

We have a really great protocol. If you want to email me, I will send it to you.

Hey thank you very much. I would love to see your protocol. Please PM me.

thanks again!

jmgrn65, RN · Aug 8, 2005

I am curious how this is used on the floors with the frequent checking of blood sugars, at least of every hour. How does the floor nurse with at least 4 patient take care of someone on insulin gtt? We are using it in our icu's, first started with our open heart surgical patients.

Mili · Aug 8, 2005

Our blood sugars are collected by laboratory personnel. Nurses do not do ancillary tasks at my facility. We have RT, PT, lab for that. We have not had any problems with the insulin protocol. When we first started it, I had one of the pharmacists come to my staff meeting--which I made mandatory for RN's. We involved the nursing staff with the development of the protocol and the rest has been a piece of cake. I have found that if you involve the staff, you will save yourself a lot of grief later. The nurses feel that they have really been a part of the process, which has really diffused a lot of problems.

KEK RN · Sep 4, 2005

I have experienced the "insulin protocol" at my facility! I was terminated from my position because of it. I walked into a pt room and the gtt was running at 160 cc/hr. I was just getting report and noticed this. Instantly I told the night nurse that was an inappropriate rate. I checked the blood sugar immediately and called the MD. I turned off the gtt and continued to have low blood sugars. I kept calling the MD and he said he would be in to look at the pt. He then wrote orders to stop gtt (which I did 2 hours prior) and do accuchecks-bloodsugar checks QID and give Lantus 26 Units now and qam. I told him I had BS in the 50's and he still said to do checks QID. I ended up doing about 14 blood sugars that day on my pt that was to have QID checks. I was told I didn't do checks enough, and I did do one late entry documentation. That is why I was terminated.

That day I looked at the original order, the order stated "start insulin gtt as protocal" come to find out we didn't have a protocal. We had a one page "draft" that shouldn't have even been out on the floor.

I'm thinking of filing a grievence, but don't know the proceedure, was wondering also if there are lawyers that specialize in this.

P_RN, ADN, RN · Sep 4, 2005

If all is as you say KEK then I believe a grievance at least is in order. Do you work at the facility or are you a traveller/agency nurse? When did you know the facility had no written policy? The HCP who wrote the order should have been written up IMHO.

That being said, I admit I have never worked with a insulin drip protocol, but have worked with a heparin protocol. Even then the doctors never agreed what a standard mix was.

An on the floor insulin drip monitored as frequently as q1h is virtually impossible. My mimimum # of patients would have been 10 with a partner or 15 with a partner and a tech. No way I could have followed anything q1h.

Please follow up on this. It sounds to me that you at least saved this patient from dire hypoglycemia.

hrtprncss · Sep 4, 2005

i'm curious what happened to the other nurse that left the drip running at 160cc/h, i mean am i correct by assuming that concentration is 1u/cc.

brutuss7 · Sep 4, 2005

I have experienced the "insulin protocol" at my facility! I was terminated from my position because of it. I walked into a pt room and the gtt was running at 160 cc/hr. I was just getting report and noticed this. Instantly I told the night nurse that was an inappropriate rate. I checked the blood sugar immediately and called the MD. I turned off the gtt and continued to have low blood sugars. I kept calling the MD and he said he would be in to look at the pt. He then wrote orders to stop gtt (which I did 2 hours prior) and do accuchecks-bloodsugar checks QID and give Lantus 26 Units now and qam. I told him I had BS in the 50's and he still said to do checks QID. I ended up doing about 14 blood sugars that day on my pt that was to have QID checks. I was told I didn't do checks enough, and I did do one late entry documentation. That is why I was terminated.
That day I looked at the original order, the order stated "start insulin gtt as protocal" come to find out we didn't have a protocal. We had a one page "draft" that shouldn't have even been out on the floor.
I'm thinking of filing a grievence, but don't know the proceedure, was wondering also if there are lawyers that specialize in this.

KEK, can you get documentation regarding why you were terminated? Then, you could address each 'reason' in the form of a grievance. If you made a mistake, wouldn't it be more productive to coach you, rather than get rid of you? What happened to the person who set the rate at 160/hour? Also, if the administration is trying to protect the MD at your (and not to mention, the patient's) expense, you may have a whistle-blower's defense. Lastly, you don't mention getting a supervisor involved with the problem early on. Gathering a group of witnesses upon discovery of a problem is always a good tactic. Others can document your efforts as they saw it.