Safety and efficacy of a pharmacist-driven protocolized transition from insulin infusion to subcutaneous insulin in patients undergoing cardiothoracic surgery

Introduction

Few validated approaches exist for the transition from intravenous (IV) insulin infusion to subcutaneous (SQ) insulin post-operatively in cardiothoracic surgery patients.

Objective

This study aimed to assess whether a pharmacist-driven protocol utilizing basal, prandial, correctional, or correctional-only SQ insulin is safe and efficacious for post-operative glycemic control following 24 h of IV insulin administration.

Methods

A retrospective, single-center, observational study investigating outcomes associated with a pharmacist-driven protocol utilizing basal, prandial, correctional, or correctional-only insulin from May 2023 through July 2023 when compared with a historical nursing-driven protocol observed from May 2021 through July 2021. Adult cardiac intensive care unit patients who received an insulin infusion within 24 h of cardiothoracic surgery and subsequently transitioned to SQ insulin were observed. The primary outcome was percentage of blood glucose (BG) readings at goal (140–180 mg/dL). Secondary outcomes included percentage of BG readings in a clinically acceptable range (110–180 mg/dL), hypoglycemia (<70 mg/dL), severe hypoglycemia (<40 mg/dL), administration of rescue dextrose, reinitiation of insulin infusion following transition, and surgical site infection.

Results

Use of a pharmacist-driven protocol improved the percentage of BG readings in goal range when compared with a nursing driven protocol (24.4% vs. 12.4%, p = 0.001). More BG readings were in the clinically acceptable range in the pharmacist-driven group: 69.6% of readings versus 58.5% in the nursing-driven group (p = 0.011). There were fewer hypoglycemic events in the pharmacist-driven group. There were no reports of severe hypoglycemia, further IV insulin requirements, or surgical site infections in either group. Pharmacist compliance to the protocol was high at 92.4%.

Conclusions

A pharmacist-driven protocolized approach to the transition to SQ insulin post-operatively in cardiothoracic patients is both safe and efficacious. The pharmacist-driven protocol resulted in an improved percentage of BG readings in goal range and fewer hypoglycemic events when compared with the historical nursing-driven protocol.