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RHONDA S. REA, PHARM.D., is Assistant Professor, Pharmacy and Therapeutics, Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh (UP), and Critical Care Specialist, Medical Intensive Care Unit, UP Medical Center, Pittsburgh, PA. AMY CALABRESE DONIHI, PHARM.D., is Assistant Professor, Pharmacy and Therapeutics, Department of Pharmacy and Therapeutics, UP. MARYBETH BOBECK, PHARM.D., is Cardiovascular Clinical Pharmacist, Department of Cardiac Services, New Hanover Regional Medical Center, Wilmington, NC. PETER HEROUT, PHARM.D., is Clinical Coordinator, Medical Intensive Care Unit, Advocate Christ Medical Center, Oak Lawn, IL. TERESA P. MCKAVENEY, B.S., is Research Assistant, Department of Pharmacy and Therapeutics, UP. SANDRA L. KANE-GILL, PHARM.D., M.SC., is Assistant Professor, Center for Pharmacoinformatics and Outcomes Research, UP. MARY T. KORYTKOWSKI, M.D., is Professor of Medicine, Division of Endocrinology, Department of Medicine, and Medical Director, Center for Diabetes and Endocrinology, UP, and Chair, UP Medical Center Diabetes Patient Safety Committee.

Address correspondence to Dr. Rea at the Department of Pharmacy and Therapeutics, 200 Lothrop Street, 302 Scaife Hall, Pittsburgh, PA 15213 (rears{at}msx.upmc.edu).

Purpose. The implementation of three different insulin protocols in intensive care unit (ICU) settings in two community hospitals and one academic hospital is described. Summary. Each institution possessed a commitment to improve the existing insulin protocols in order to achieve tighter glycemic control for ICU patients. Studies have shown that the maintenance of tight glycemic control provides improved patient outcomes. Obstacles to implementation of the insulin protocols at the institutions were increased staff workload, difficulties in interpreting algorithms, and lack of perceived benefit. In comparing details of the insulin protocols at the academic and community hospitals, it was found that differences were influenced by the type of institution. The differences among the institutions in the implementation of the protocols included the initial physician response to the protocol, the details of each protocol, nursing staff autonomy, and the involvement of the nursing staff in early protocol development. All three institutions had a dedicated pharmacist in the ICU who committed time toward insulin protocol implementation. For an increased likelihood of successful insulin protocol implementation, a full-time dedicated ICU pharmacist should be assigned to participate on multidisciplinary rounds, provide nursing support and education, and collect process measures to monitor and improve the protocol. Conclusion. The i.v. insulin infusion protocols developed and implemented in the ICUs at three institutions successfully achieved acceptance and compliance by physicians and nurses. The factors attributed to the success were multidisciplinary involvement, the continuous education of nursing staff, the vigilant involvement of a pharmacist, and flexibility in revising the protocol. Index terms: Hospitals; Injections; Insulin; Insulins; Pharmacists, hospital; Physicians; Protocols; Workload