PURPOSE: Treatment protocols and guidelines are essential tools to decrease medical errors and improve care in an Intensive Care Unit (ICU) setting. Control of hyperglycemia is a goal in most adult and an increasing number of pediatric ICUs. The goal of glucose control provides an opportunity to create a decision support tool common to both adults and children. A computerized insulin protocol can provide explicit and non-ambiguous instructions for titrating insulin and controlling hyperglycemia. We describe the development, refinement, and validation of an insulin infusion computerized protocol (eProtocol_insulin) for blood sugar control in adult and pediatric ICU patients.
METHODS: The rules for each protocol version were analyzed and discussed by the computer protocol development research group at LDS Hospital. Insulin protocol rules were initially developed and extensively tested for adult patients. Weight adjustment of the adult protocol created the pediatric version. Each version was tested against possible clinical scenarios and different patient weights. The logic and acceptability of the clinical instructions were reviewed by each member of the development research group to determine feasibility and safety of the instruction. The program was then placed in a pediatric ICU (PICU) clinical environment with onsite physician/developer oversight. In addition 5 PICU clinicians were surveyed to independently provide their own set of insulin titration instructions for a set of 193 clinical scenarios. The clinicians' instructions were then compared to the eProtocol_insulin instructions.
RESULTS: Comparing eProtocol_insulin adults vs. pediatrics: measurements (adults 19,849 vs. peds 2,234), average glucose•SD (113•40 vs. 121•57), % measurements < 60 mg/dl (1.22%, vs. 0.72%), % measurements • 40 mg/dl (0.1% vs. 0.04%), compliance with instructions (95% vs. 89%).
CONCLUSION: Careful development with batch testing and supervised controlled clinical experience allowed safe and effective refinement of a computerized insulin infusion protocol for glucose control in both adult and pediatric ICUs.
CLINICAL IMPLICATIONS: Computerized protocol's can provide a framework for standardizing and improving care in both pediatric and adult critical care settings.
DISCLOSURE: Ellie Hirshberg, None.