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Hospital Pharmacy 53(2)
amount of different protocols in use likely contributed to
protocol violations. Our data together with nursing feedback
and updated glucose targets demonstrate the need to create
and consolidate usage to a single protocol in attempts to
improve glycemic control.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

Figure 1. Glucose variability as measured by hours within the
goal blood glucose range for each protocol used.

Further, none of the 4 protocols achieved acceptable control as evidenced by time within goal range. Glucose variability accounted for nearly one-third of the hypoglycemic
events. During data analysis, the authors observed large
decreases in glucoses occurred immediately prior to many of
the variability-associated events, which all 4 protocols fail to
address. The authors believe not only consolidating to one
protocol is necessary, but perhaps a new protocol be established that incorporates the change in glucose.
This study has several limitations. This study was not
powered to detect differences in outcomes in patients incurring hypoglycemic events; however, clinical outcomes were
not the focus of this study. Subjectivity and investigator bias
could have played a role in assigning definitive cause for
each episode. In best efforts to avoid bias, 2 separate authors
independently assessed each event. The hypoglycemic group
had a larger portion of patients with a history of diabetes.
Because these patients have underlying issues regulating
insulin and glucose, they may be more susceptible to variability in glucose levels. The blood glucose levels were measured using point of care bedside testing. Bedside glucose
testing has been shown to result in falsely elevated blood
glucose levels in critically ill patients in the intensive care
unit.11 Thus, some incidences of hypoglycemia may have
been missed. No patient was receiving any other agent other
than insulin to assist in glycemic control. Future efforts may
be aided by use of additional agents to reduce insulin resistance and gluconeogenesis, specifically metformin.12
The overall rates of hypoglycemia, blood glucose variability, and protocol violations raise concerns about the protocols in use during the time period of the study. Education to
increase protocol adherence is unlikely to achieve adequate
control, as evidenced by the high percentage of patients with
large drops in glucose in absence of protocol violations. The

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Table of Contents for the Digital Edition of Hospital Pharmacy - April 2018