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Wisconsin Insulin Infusion – Adult – Inpatient [6]

Wisconsin Insulin Infusion – Adult – Inpatient [6] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Practice Protocols


Practice Protocol Number:  6 
Practice Protocol Title:  
Wisconsin Insulin Infusion ‐ Adult ‐ Inpatient 
Practice Protocol Applies To:  
All UWHC Hospital Inpatient Units excluding B65 and Inpatient Psychiatry. Also includes American Family 
Children’s Hospital (AFCH) Adult PICU Patients 
Target Patient Population:  
Adult patients who require intravenous insulin infusion 
Practice Protocol Champion: 
Vanessa Rein, MD ‐ Department of Medicine, Division of Endocrinology 
Practice Protocol Reviewer: 
Gwen Klinkner, CNS – Nursing Practice Innovation 
Responsible Department: 
Department of Nursing 
Purpose Statement: 
The Wisconsin Insulin Infusion Practice Protocol is intended to clearly delineate the steps to be taken for 
safe administration of intravenous insulin specifically related to infusion rate adjustment based on blood 
glucose results. 
Who May Carry Out This Practice Protocol: 
Registered Nurses (RNs) trained in the use of this practice protocol 
Guidelines for Implementation: 
1. The Practice Protocol is to be used for insulin infusion rate adjustment when a provider order is
given to initiate “insulin regular (human) 250 units in sodium chloride 0.9% 250mL infusion”
with administration instructions such as “Administer insulin drip in accordance with Insulin
Infusion Practice Protocol – Adult – Standard Dose” (and HIGH DOSE when applicable in ICUs
only).
2. Orders for glucose monitoring, hypoglycemia treatment and subcutaneous insulin to coincide
with meals will be included in the IP – Insulin Infusion – Adult – Supplemental order set or
within an Insulin Infusion order panel.
3. A provider order is required for discontinuation of the insulin infusion.
4. After a provider order is given to discontinue the insulin infusion, nurses may discontinue
collateral orders “per protocol” for hourly glucose monitoring if alternative point of care (POC)
glucose monitoring orders have been given (i.e., before meals and bedtime).RNs may also
discontinue the collateral order “per protocol” related to priming intravenous tubing with
insulin. RNs may not discontinue hypoglycemia treatment orders.
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2016CCKM@uwhealth.org

Collateral Documents/Tools: 
Wisconsin Insulin Infusion (STANDARD DOSE) ‐ Adult ‐ Practice Protocol 
Wisconsin Insulin Infusion (HIGH DOSE) ‐ Adult ‐ Practice Protocol (ICU ONLY) 
References: 
Association AD. 13. Diabetes Care in the Hospital.  Diabetes Care. Jan 2016;39:S99‐104. 
Kansagara D, Fu R, Freeman M, Wolf F, Helfand M.  Intensive Insulin Therapy in Hospitalized Patients: A 
Systematic Review.  Annals of Internal Medicine. 2011;154:268‐W289. 
American Diabetes Association. Diabetes Care in the Hospital, Nursing Home, and Skilled Nursing 
Facility. Diabetes Care. 2015;38:S80‐S85. 
Krikorian A, Ismail‐Beigi F, Moghissi ES. Comparisons of different insulin infusion protocols: a review of 
recent literature. Current opinion in clinical nutrition and metabolic care. 2010;13:198‐204.  
Magaji V, Johnston JM. Inpatient Management of Hyperglycemia and Diabetes. Clinical Diabetes. 
2011;29:3‐9. 
Approved By: 
UWHC Nursing Practice Council: April 2012; August 2015 (expedited process), March 2016 (expedited 
process) 
UWHC Pharmacy & Therapeutics Committee:  April 2012; August 2015 (expedited process), Marchl 2016 
(expedited process) 
UWHC Medical Board: May 2012; August 2015 (expedited process), March 2016 (expedited process) 
Effective Date:  March 2016 
Scheduled for Review:  March 2019 
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2016CCKM@uwhealth.org

Wisconsin Insulin Infusion (HIGH DOSE) - Adult - Practice Protocol (ICU ONLY)
Last Updated February 2016
Glucose Monitoring Orders
Perform Blood Glucose Monitoring (bedside) every hour until within Target Range (110-150 mg/dL) for
3 hours (3 readings in a row), then decrease frequency to every 2 hours. Hourly monitoring must be
resumed if blood glucose deviates from Target Range. Serum monitoring only for patients with Hct<20%,
compromised circulation, and any other conditions specified in Policy 11.26.
Rules for the Use of Columns 7-9:
 A patient must be in the ICU to use the HIGH DOSE columns 7-9. If criteria are met to move into column 7 for general care/IMC
patient currently in Column 6, notify provider/ DMS to determine if SC insulin could be added or if ICU transfer is warranted.
 A patient must be using Column 6 and meet criteria to move right 1 column in order to transition to Column 7.
 When criteria are met to move left 1 column for a patient using Column 7, patient should be moved back to Column 6 of the STANDARD
DOSE Insulin Infusion Protocol.
Rules for Making Rate and Column Changes
1. Determine the amount of change in blood glucose since the
previous glucose check; follow decision tree below.
2. Do not move more than one column each hour unless
specifically ordered.
3. Nutritional Considerations: If SQ rapid-acting insulin
(aspart/lispro) is administered with meals, stay in the same column
for the next 2 hours; continue to adjust rate based on hourly BG
checks. Two hours after SQ insulin is given, resume use of
decision tree below.
4. Consider moving right after initiation or increase of vasopressors
or steroids (including epinephrine, norepinephrine, vasopressin,
prednisone, dexamethasone, methylprednisolone, and/or
hydrocortisone), tube feeding or TPN if BG values increase with
subsequent monitoring.
5. Consider moving left after reduction or discontinuation of
medications (as above), tube feeding or TPN, or 2-4 hours after
giving 1st dose of subcutaneous basal insulin (i.e., glargine) if BG
values decrease with subsequent monitoring.
Column 7 Column 8 Column 9
BG Units/hr BG Unit/hr BG Units/hr
>360 38 >360 46 >360 54
330-359 36 330-359 42 330-359 48
300-329 34 300-329 38 300-329 44
270-299 30 270-299 34 270-299 38
240-269 26 240-269 30 240-269 34
210-239 22 210-239 26 210-239 30
180-209 18 180-209 22 180-209 26
151-179 15 150-179 18 150-179 22
T
ar
ge
t
Ra
ng
e 140-150 12 140-149 15 140-149 18
130-139 10 130-139 12 130-139 15
110-129 8 110-129 10 110-129 12
BG less than 110 mg/dL : Move left 1 column every hour until BG is back
within Target Range; revert to columns 1-6 as needed
100-109 5 100-109 6 100-109 8
90-99 4 90-99 5 90-99 7
70-89 3 70-89 3 70-89 5
<70 Off <70 Off <70 Off
BG less than 70 mg/dL = hypoglycemia
(see right for Hypoglycemia Management)
Amount of Change
> 100 mg/dL
In Target
Below
Target
Above
Target
BG 70-109 mg/dL
Move left one
column;
Adjust rate
Stay in same
column;
Adjust rate
1st time: Stay
in same
column;
Adjust rate
2nd
consecutive
occurrence:
Move right
one column;
Adjust rate
If BG is
increasing,
move right
one column;
adjust rate
Amount of Change
50 – 100 mg/dL
In Target
Below
Target
Above
Target
BG 70-109 mg/dL
Move left one
column;
Adjust rate
Stay in same
column;
Adjust rateBG< 70 mg/dL
Turn off, follow
Hypoglycemia
orders
Stay in same
column;
Adjus t rate
BG< 70 mg/dL
Turn off,
follow
Hypoglycemia
orders
If BG is
decreasing,
move left
one column;
adjust rate
Amount of Change
0 – 49 mg/dL
Hypoglycemia Management (BG <70 mg/dL)
STEP 1: Stop infusion. (Infusion should be off for at
least 30 minutes; See step 4, below, for how
to re-start).
STEP 2: Provide treatment as ordered.
STEP 3: Recheck glucose within 15 minutes after
treatment. Repeat treatment as ordered until
BG ≥ 70 mg/dL. Another BG will need to be
checked before re-starting infusion.
STEP 4: Re-start infusion if insulin has been off for
30 minutes AND if current BG is 110
mg/dL or greater. Move Left 1 column and
restart infusion rate according to current
glucose value (**If hypoglycemia occurred
while patient was in Column 7, move to
Column 6 of STANDARD Insulin Infusion
Protocol when time to re-start.)
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2016CCKM@uwhealth.org

Wisconsin Insulin Infusion (STANDARD DOSE) - Adult - Practice Protocol
Last Updated February 2016
Column 7-9
Only for use
in ICUs
If criteria are
met to move
into column 7
for general
care/IMC
patient
currently in
Column 6,
notify
provider/
DMS to
determine if
SC insulin
could be
added or if
ICU transfer
is warranted.
Glucose Monitoring Orders
Perform blood glucose monitoring every hour until within Target Range (110-150 mg/dL) for 3 hours (3
readings in a row), then decrease frequency to every 2 hours. Hourly monitoring must be resumed if blood
glucose deviates from Target Range. Serum monitoring only for patients with Hct<20%, compromised circulation,
and any other conditions specified in Policy 11.26.
Initiating the Infusion (NOTE: After priming IV tubing, waste additional 20 mL of insulin to saturate all tubing bi nding sites.)
Column 1: Only start here for extremely insulin sensitive patients
(i.e., patients with type 1 diabetes using less than 30 units insulin/day at home or s/p islet transplant)
Column 2 : Start here for most patients. (Note exceptions for Column 1 or 3)
Column 3: Start here if patient meets at least 1 of the following conditions: glucose level ≥ 600 mg/dL; s/p cardiac surgery or solid organ transplant
(this admission); receiving vasopressors such as epinephrine, norepinephrine, vasopressin OR steroids such as prednisone, dexamethasone,
methylprednisolone, hydrocortisone; history of diabetes usiQJ ≥ �� XQLWV�GD\ RI LQVXOLQ DV DQ RXWSDWLHQW
Columns 4-6: Do Not Start Here.
Rules for Making Rate and Column Changes
1. Determine the amount of change in blood glucose since the previous
glucose check; follow decision tree below.
2. Do not move more than one column each hour unless specifically
ordered.
3. Nutritional Considerations: If SQ rapid-acting insulin (aspart/lispro)
is administered with meals, stay in the same column for the next 2
hours; continue to adjust rate based on hourly BG checks. Two hours
after SQ insulin is given, resume use of decision tree below.
4. Consider moving right after initiation or increase of vasopressors or
steroids (including epinephrine, norepinephrine, vasopressin,
prednisone, dexamethasone, methylprednisolone, and/or
hydrocortisone), tube feeding or TPN if BG values increase with
subsequent monitoring.
5. Consider moving left after reduction or discontinuation of
medications (as above), tube feeding or TPN, or 2-4 hours after giving
1st dose of subcutaneous basal insulin (i.e., glargine) if BG values
decrease with subsequent monitoring.

Hypoglycemia Management (BG <70 mg/dL)
STEP 1: Stop infusion. (Infusion should be off for at least 30 minutes; See step 4, below, for how to re-start).
STEP 2: Provide treatment as ordered.
STEP 3: Recheck glucose within 15 minutes after treatment. Repeat treatment as ordered until BG ≥ 70 mg/dL. Another BG will need to be checked before re-starting
infusion.
STEP 4: Re-start infusion if insulin has been off for 30 minutes AND if current BG is 110 mg/dL or greater. Move Left 1 column and restart infusion rate according
to current glucose value (**If already using Column 1, follow dosing parameters as written in Column 1).
Column 1 Column 2 Column 3 Column 4 Column 5 Column 6
BG Units/hr BG Units/hr BG Units/hr BG Units/hr BG Units/hr BG Units/hr
≥��� 3 ≥��� 6 ≥��� 12 ≥��� 18 ≥��� 26 ≥��� 30
330-359 2.5 330-359 4 330-359 9 330-359 15 330-359 24 330-359 30
300-329 2 300-329 4 300-329 8 300-329 13 300-329 22 300-329 28
270-299 1.8 270-299 3 270-299 7 270-299 11 270-299 18 270-299 28
240-269 1.5 240-269 3 240-269 6 240-269 10 240-269 14 240-269 24
210-239 1 210-239 2 210-239 5 210-239 8 210-239 12 210-239 20
180-209 1 180-209 2 180-209 4 180-209 6 180-209 10 180-209 16
151-179 0.8 151-179 1.5 151-179 3 151-179 5 151-179 9 151-179 12
T
ar
ge
t
Ra
ng
e
140-150 0.5 140-150 1.2 140-150 2.5 140-150 4 140-150 8 140-150 10
130-139 0.3 130-139 1 130-139 2 130-139 3 130-139 5 130-139 8
110-129 0.2 110-129 0.8 110-129 1.5 110-129 2.5 110-129 4 110-129 6
89-109 OFF BG less than 110 mg/dL : Move left 1 column every hour until BG is back within Target Range
Check BG hourly,
resume infusion
100-109 0.5 100-109 1 100-109 1.5 100-109 2 100-109 4
90-99 0.2 90-99 0.5 90-99 1 90-99 1.5 90-99 3
when BG >109mg/dL 70-89 0.2 70-89 0.2 70-89 1 70-89 1 70-89 1.5
<70 OFF <70 OFF <70 OFF <70 OFF <70 OFF <70 OFF
BG less than 70 mg/dL = hypoglycemia (see below for hypoglycemia management)
Amount of Change
> 100 mg/dL
In Target
Below
Target
Above
Target
BG 70-109 mg/dL
Move left one
column;
Adjust rate
Stay in same
column;
Adjust rate
1st time: Stay
in same
column;
Adjust rate
2nd
consecutive
occurrence:
Move right
one column;
Adjust rate
If BG is
increasing,
move right
one column;
adjust rate
Amount of Change
50 – 100 mg/dL
In Target
Below
Target
Above
Target
BG 70-109 mg/dL
Move left one
column;
Adjust rate
Stay in same
column;
Adjust rateBG< 70 mg/dL
Turn off, follow
Hypoglycemia
orders
Stay in same
column;
Adjust rateBG< 70 mg/dL
Turn off,
follow
Hypoglycemia
orders
If BG is
decreasing,
move left
one column;
adjust rate
Amount of Change
0 – 49 mg/dL
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 03/2016CCKM@uwhealth.org