The Variable Rate Intravenous Insulin Infusion in Clinical Practice 2015: an audit against the new JBDS guidance

Abstract

Background: Variable rate intravenous insulin infusion (VRIII) is an established method to achieve normoglycaemia in unwell or fasting patients. The Joint British Diabetes Societies (JBDS) released new guidance for the use of VRIII in medical inpatients in October 2014. This specifies the appropriate clinical circumstances in which a VRIII should be used and how it should be initiated, managed and discontinued safely.

Methods: We developed an audit tool based on the guidelines and audited the current practice at the Royal Sussex County Hospital, Brighton, prior to the roll out of the new standards. We have audited 50 patients on VRIII under non-specialist medical and surgical care.

Results: Several parameters were checked. VRIII prescription was signed appropriately as per the guidance in 98% of patients. Oral hypoglycaemic medications were omitted in 83%. Short-acting and mix insulins were omitted only in 88%. Long-acting insulin was administered only in 77% of the patients. Blood glucose was tested 1–2 hourly in 90% of patients. All patients with hypoglycaemic episodes were treated as per protocol. On the occasions where VRIII was discontinued, it was reinitiated within 20 min as per the guidelines only in 36% of cases. In patients with persistent hyperglycaemia, the rate was increased in 80% of cases.

Discussion: Clinical practice surrounding the use, appropriate management and monitoring parameters appeared to fall short of the standards suggested by the latest JBDS guidance. Our audit outcome was to prepare a protocol for the trust summarising the indications for VRIII, target capillary blood glucose, how and when to stop VRIII for patients with diabetes and also a prompt to prescribe basal insulin for patients with diabetes and when a referral should be made to the diabetes inpatient team. Introducing teaching sessions to all the professionals and raising the awareness through a hospital communication programme on the wards would also help to theoretically improve the results.

Conclusions: The majority of patients on VRIII are managed by non-diabetic teams and practice may vary from set guidance due to unfamiliarity and lack of diabetes specific knowledge. The appropriate use of VRIII needs to be tackled through remedial education, introduction of the new JBDS guidance and allied to improvements in systems and processes.