Running head: COMPUTERIZED INSULIN DOSING

Improving Glycemic Control Using a Computerized Insulin Dosing Algorithm

Danielle Finethy
University of South Florida

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Abstract

Clinical problem: Critically ill patients are at high risk for hyperglycemia and hypoglycemia
regardless of a diagnosis of diabetes.
Objective: To discuss whether use of a computerized dosing algorithm for insulin therapy is
more effective in keeping blood glucose in the target range than use of paper protocols.
Search engines and key words: PubMed and CINAHL were used to gather randomized,
controlled trials (RCT) on use of various computerized insulin dosing algorithms for patients in
intensive care (ICU). The American Diabetes Association (ADA) standards of care were
accessed attain current clinical guidelines for use of insulin therapy in critical care settings. The
key search terms used included insulin therapy, glucose control, critical care, tight glucose
control, computerized insulin, and insulin algorithm.
Results: Three RCTs conducted in clinical ICUs utilized computerized insulin dosing algorithms.
The results showed that blood glucose levels were more consistently in the target range for
glucose control when insulin was dosed using a computerized algorithm, compared to standard
paper protocol for insulin therapy. The ADA guidelines for insulin therapy in critically ill
patients outlines that use of a validated paper protocol or a computerized dosing algorithm
should be used for managing glucose control (American Diabetes Association [ADA], 2016).
Conclusion: Use of computerized insulin dosing algorithms for care of critically ill patients
leads to greater time spent in the target range for blood glucose control and less episodes of
hyperglycemia or hypoglycemia when compared to use of paper protocols. Further research is
needed to evaluate the potential long term benefits of controlling blood glucose in critically ill
individuals.

COMPUTERIZED INSULIN DOSING

Improving Glycemic Control Using a Computerized Insulin Dosing Algorithm

Hyperglycemia is often seen in critically ill patients regardless of a diagnosis of diabetes
and common causes are excess release of stress hormones, medications, and dietary changes
(Hsu, 2012). The drastic changes in glucose levels seen in this patient population contribute to
worsened patient outcomes and overall health during recovery and after discharge.
Hyperglycemia has been linked to poor outcomes including increases in morbidity and mortality
in severe illness, decreased immune function, cardiac complications, and various other problems
(Hsu, 2012). These findings indicate that glucose control is extremely important for improving
care for critically ill patients. Utilizing computerized insulin dosing algorithm technology is one
way to help improve blood glucose levels. This paper will examine three randomized controlled
trials that have used computerized insulin dosing algorithms in intensive care units (ICU). The
aim is to determine if use of a standard paper protocol compared to the computerized algorithm
will result in better glucose control.
Literature Search
PubMed and CINAHL were used to find randomized, controlled trials (RCT)
investigating the use of computerized insulin dosing algorithms in intensive care clinical settings.
The American Diabetes Association was accessed to obtain the current clinical guidelines for
insulin therapy in critically ill patients. The search terms used were insulin therapy, glucose
control, critical care, tight glucose control, computerized insulin, and insulin algorithm.
Literature from 2011 to 2016 was included in the search.
Literature Review
To evaluate the effectiveness of computerized insulin dosing algorithms on blood glucose
control in critical care settings, three RCTs and one clinical guideline were reviewed. Dumont

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and Bourguignon (2012) conducted a prospective, randomized controlled research study to

determine if use of a computerized insulin-dosing calculator (CIDC) compared to standard paper
protocol was more effective in maintaining glucose control within a targeted range of 80-150
mg/dl. Eligible patients were those who required intravenous insulin and were critically ill.
There were a total of 300 patients included in the study, all of which were randomized to one of
two groups, with (n=159) randomized to the control group and (n=141) to the intervention group.
All patients were receiving intravenous insulin during the study and participation was terminated
after blood glucose readings reached the target range for three consecutive readings, if the
participant was discharged from the unit, or if use of intravenous insulin was stopped for four or
more hours. The control group received insulin dosing changes based on standard paper protocol
and the intervention group received insulin dosing changes determined by the CIDC. Outcome
measures included the amount of time spent in the target range and mean glucose variability.
There was a statistically significant difference in the percentage of blood glucose readings in the
target range for the CIDC group compared to the control group (p< .001). The variability in
blood glucose was also significantly less for the CIDC group than the control group (p< .001).
Each of the two groups were reported to have similar demographic and baseline clinical values.
Weaknesses of the study were that nurses involved in patient care were not blind to intervention
or control groups, the study took place at a single site, and that follow up assessment data is
unknown. The strengths included the randomization of all study participants, outcome assessors
being blind to the randomization of participants, the similarities in demographic and clinical
values of all participants involved in study, and the measures used to evaluate effectiveness.
Additional strengths included description of reasons why participants may not have completed

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the study, an appropriate control group, and analyzing data from participants to the original
randomized group they were assigned to.
Leelarathna et al. (2013) conducted an investigator-initiated, prospective single-center
randomized controlled parallel-group open-label trial to determine if use of continuous blood
glucose monitoring along with automated insulin infusion pumps and dextrose infusion pumps
will result in patients having more time logged in the desired range for blood glucose levels than
by using standard protocol. Standard protocol included capillary blood glucose checks and nurse
initiated changes in insulin dosing based on predetermined parameters. For inclusion in the
study, patients had to be greater than 18 years old, be expected to stay on the unit for at least 48
hours, have an arterial blood glucose reading of 10 mM or have already been receiving insulin,
or have an existing diagnosis of diabetes. The total number of participants was 24, with (n=12)
randomized to the control group and (n=12) to the intervention group. The control group
received insulin therapy based on standard paper protocol and the trial group received the closedloop glucose-control system. Outcome measures were the amount of time blood glucose levels
were in the target range and mean glucose levels throughout the trial. The target range was
between 6 and 8 mM, which, when converted to the unit of measurement of mg/dl equals 108144 mg/dl. The results of the study showed that use of the closed-loop system was significantly
more effective in keeping blood glucose levels within the targeted range than with the standard
protocol (p= .001). The mean glucose levels in the trial group were lower and more consistent
than the control group (p= .001). The weaknesses of the study include small sample size and that
the nurses providing care were not blind to the study. Additional weaknesses are that the
investigator was not blind to participants at the time of randomization and that follow up
measures of participants are not described. The strengths included randomization of participants

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through minimization using the Minum computer program, specified outcomes and valid
evaluation techniques, explanations given as to why participants may not have completed the
study, similar in demographic and baseline clinical values of all participants, and an appropriate
control group. All participants were analyzed in the groups to which they were randomly
assigned.
Van Herpe et al. (2013) conducted an investigator-initiated, single-center, prospective
randomized controlled parallel-group trial to determine if the LOGIC-Insulin computerized
algorithm was more effective in treating hyperglycemia than use of a standard protocol.
Eligibility criteria included admission to the ICU and the need for tight glucose control (TGC).
The total number of participants was 300, with (n=151) randomized to the control group and
(n=149) to the intervention group. The purpose of the study was to determine if use of the
LOGIC-Insulin computerized algorithm compared with the standard paper-based protocol used
by nurses highly trained in TGC will result in patients experiencing better TGC with blood
glucose levels in the targeted range. The target range was 80-110 mg/dL and severe
hypoglycemia defined as less than 40 mg/dL. The primary outcome measure of the trial was
identified as the glycemic penalty index (GPI), which assigned a score from 0-100 any time a
patients blood glucose was outside of the TGC target range. The score was relative to the
deviation from TGC. The results of the study show that patients assigned to the LOGIC-1 group
experienced greater time in the target range than the Nurse-C group (p< .00016). The GPI of the
LOGIC-1 group was also significantly lower than the Nurse-C group (p< .0001). A weakness of
the trial was that the nurses were not blind to the control and intervention groups. Another
weakness of the trial is that the nurses involved were highly trained in managing insulin dosing
with the standard protocol, so the awareness of the study may have further increased the efficacy

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in which they provided care, which may have affected results. Strengths of the trial include the
randomization of all participants, the similarities of each group with regard to demographic and
baseline clinical values, reasons provided for participants not completing the study, and valid
follow up of participants after study conclusion. Strengths of the trial also include having
outcome assessors blind to the treatment allocations, all participants analyzed in the groups to
which they were randomized to, an appropriate control group, and valid and reliable tools used to
measure outcomes.
The ADA standards of care for 2016 state that for most critically ill patients who require
insulin therapy, a blood glucose range of 140-180 mg/dL should be the goal (ADA, 2016). The
more stringent goal of 110-140 mg/dL is another option for patients who have previously
responded well with targeted treatment goals in this range (ADA, 2016). The guidelines also
include that these levels should be monitored and insulin dosing adjusted by use of a validated
paper protocol or a computerized insulin dosing algorithm (ADA, 2016). These guidelines were
developed using evidence from various RCTs related to insulin dosing methods and glucose
control goals.
Synthesis
The RCTs reviewed for the purpose of answering which method of insulin dosing results
in better glucose control all used similar processes, but had distinct differences. Dumont and
Bourguignon (2012) utilized a dosing calculator that applied the last four glucose readings and
the response the previous dose of insulin had on blood glucose before determining the amount of
the next dose. This study found that use of the CIDC resulted in significantly higher percentage
of blood glucose readings in the target range (p< .001) and less variability of blood glucose than
in control group (p< .001). Van Herpe et al. (2013) used a similar program called LOGIC-

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Insulin computerized algorithm. The LOGIC-I algorithm required the blood glucose readings to
be entered into the program and based on the most recent reading it would calculate the dosage
of insulin or dextrose infusion required to keep the patient in the target range. This system
provided treatment guidance for hypoglycemic and hyperglycemic events. The results of this
study showed that the LOGIC-I group experienced more time spent in the target range than the
control (p< .00016). The LOGIC-I group also had a lower GPI than the control group (p< .
0001). Hypoglycemic episodes occurred more in the control group than the intervention, (p< .
0048).
A different type of system was utilized by Leelarathna et al. (2013) that used a
completely closed loop system to provide blood glucose monitoring, insulin dosing, and dextrose
infusions, if needed, without intervention from nursing staff. This system allows a continuous
glucose monitor to be worn and to send real time measurements to the computerized algorithm
which then sends titration changes to the infusion pump of insulin and dextrose infusions to keep
blood glucose readings in the target range. The intervention group spent significantly more time
in the target glucose range than the control group (p= .001). This is method is different from the
other studies reviewed in that it is a closed loop. The implications this could have on nursing
practice are improvements in time management and reduced episodes of hypoglycemia, as well
as improved glucose control in critically ill patients.
Use of technology in patient care is always improving and the use of computerized
dosing algorithms has shown to be more effective than standard paper protocols in keeping
patients blood glucose in an acceptable range for critical care guidelines. The closed loop
system used by Leelarathna et al. (2013) has one aspect that the other two studies reviewed were
lacking and that is the continuous glucose monitoring. Utilizing real time readings of blood

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glucose allows any significant drops or rises to be detected almost immediately and will provide
faster treatment. The best range for blood glucose control in critically ill patients is still
unknown and all three of RCTs reviewed used a different target range for their studies.
Clinical Recommendations
The recommended range of blood glucose levels for critically ill patients is not
standardized by any one organization and further research is needed to achieve this. There is
agreement that control of hyperglycemia and avoidance of hypoglycemia is necessary to best
provide care for this population. Based on the results of the previously discussed RCTs, the use
of computerized insulin dosing algorithms will decrease variability of blood glucose and allow
for individualization of insulin dosing. A closed-loop system that utilizes continuous blood
glucose monitoring can further improve patient care by reducing frequency of point of care
checks and lessening nurse burden.

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References

American Diabetes Association. (2016). Diabetes care in the hospital. [Sec. 13. In Standards of
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10.2337/dc16-S01
Dumont, C., & Bourguignon, C. (2012). Effect of a computerized insulin dose calculator on the
process of glycemic control. American Journal of Critical Care, 21(2), 106-115. doi:
10.4037/ajcc2012956
Hsu, C.-W. (2012). Glycemic control in critically ill patients. World Journal of Critical Care
Medicine, 1(1), 31-39. doi: 10.5492/wjccm.v1.i1.31
Leelarathna, L., English, S. W., Thabit, H., Caldwell, K., Allen, J. M., Kumareswaran, K.,
Hovorka, R. (2013). Feasibility of fully automated closed-loop glucose control using
continuous subcutaneous glucose measurements in critical illness: A randomized
controlled trial. Critical Care, 17(4), R159. doi.org/10.1186/cc12838
Van Herpe, T., Mesotten, D., Wouters, P. J., Herbots, J., Voets, E., Buyens, J., Van den Berghe,
G. (2013). LOGIC-Insulin algorithmguided versus nurse-directed blood glucose control
during critical illness: The LOGIC-1 single-center, randomized, controlled clinical trial.
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