.jpg "Serena Dine, PharmD, BCPS, BCCCP photo")
Serena Dine, PharmD, BCPS, BCCCP
Clinical Pharmacy Specialist, Trauma and Surgical Critical Care
Eskenazi Health
Indianapolis, Indiana
Disclosure information not submitted.
Jenna Gerhardt, PharmD
PGY2 Internal Medicine Pharmacy Resident
Eskenazi Health, United States
Disclosure information not submitted.
David Foster, PharmD, FCCP
Associate Professor of Pharmacy Practice
Eskenazi Health, United States
Disclosure information not submitted.
Andrew Lodolo, PharmD, BCPS, BCCCP, FCCM
Inpatient Pharmacy Manager
Eskenazi Health, United States
Disclosure information not submitted.
Allyson McIntire, BCCCP, BCPS, PharmD
PharmD
Eskenazi Health, United States
Disclosure information not submitted.
Michael Peters, PharmD, MBA, BCPS
Pharmacy Business Manager
Eskenazi Health, United States
Disclosure information not submitted.
Taylor Rhew, PharmD, BCCCP
Inpatient Pharmacist
Eskenazi Health, United States
Disclosure information not submitted.
Todd Walroth, PharmD, BCPS, BCCCP, FCCM
Clinical Pharmacy Manager
Eskenazi Health, Indiana, United States
Disclosure information not submitted.
Title: Development of a Pharmacist-Managed Protocol for Transition from Intravenous to Subcutaneous Insulin
Introduction: Glycemic control decreases morbidity and mortality in the critically ill. An insulin infusion is recommended for most ICU patients requiring insulin; however, limited guidance exists regarding the transition from intravenous (IV) to subcutaneous insulin. The objective of this study is to evaluate the efficacy and safety of a pharmacist-driven protocol compared to a standard physician-managed process to transition from IV to subcutaneous insulin.
Methods: A retrospective, single-center, observational study was performed. Critically ill adults receiving a continuous insulin infusion were identified. The primary objective was percentage of blood glucose (BG) concentrations within 70-150 mg/dL within 48 hours of transition from IV to subcutaneous insulin.
Results: A total of 135 patients were included (n=40 pharmacist transition, n=95 provider transition). The pharmacist-managed group achieved BG control in 53% of transitions at 12 hr, 40% at 24 hr, and 47% at 48 hr, while the provider group achieved control in 25% at 12 hr, 12% at 24 hr, and 18% at 48 hr (p < 0.001). Lower rates of hypoglycemia (1% vs 3.8%, p=0.001), severe hypoglycemia (0% vs 0.4%, p = 0.332), hyperglycemia (28% vs 78%, p = 0.001), and severe hyperglycemia (27% vs 57%, p < 0.001) occurred in the pharmacist-managed group. Fewer insulin dose adjustments occurred after transition in the pharmacist-managed group (52% vs 83%, p < 0.001). Patients received a recommend overlap of basal and IV insulin for 1-2 hr more commonly with pharmacist-managed transitions (86% vs 40%, p < 0.001). There was no difference in re-initiation of IV insulin (7% vs 19%, p = 0.121), hospital length of stay (15 days vs 12 days, p = 0.145), ICU length of stay (11 days vs 6 days, p = 0.315), or mortality (53% vs 53%, p = 0.971) between the pharmacist and physician groups, respectively.
Conclusions: The pharmacist-managed protocol was safe and effective. Implications of this protocol include optimized glycemic control and reduced hypoglycemia for critically ill patients being transitioned from IV to subcutaneous insulin, enhanced multidisciplinary collaboration, reduced provider burden, and expansion of clinical pharmacy services.