Guideline-Concordant Insulin Infusion Initiation Among Critically Ill Patients With Sepsis.

Abstract Objective To benchmark rates of guideline-concordant insulin infusion initiation, identify factors associated with guideline-concordant insulin practices, and examine the association between hospital-level guideline concordance and mortality among critically ill patients with sepsis. Methods We performed a multicenter retrospective cohort study of intensive care patients with sepsis who were eligible for insulin infusion initiation according to American Diabetes Association and Surviving Sepsis guidelines (persistent blood sugar ≥180 mg/dL). We then identified patients who were initiated on insulin infusions within 24 hours of eligibility. We examined patient- and hospital-level factors associated with guideline concordant insulin infusion initiation and explored the association between the hospital-level proportion of patients who received guideline-concordant insulin infusions and hospital mortality. Results Among 5453 guideline-eligible patients with sepsis, 13.4% (95% CI 12.6-14.4%) were initiated on insulin infusions. Factors most strongly associated with guideline-concordant insulin infusion initiation were mechanical ventilation (OR 4.0, 95% CI 3.0-5.3) and hospital of admission (median OR 2.4, 95% CI 2.1-2.6). The hospital-level proportion of patients who received guideline-concordant insulin infusions was not associated with mortality (aR 1.4 [per 1-SD increase], 95% CI 0.5-3.8). Among 1501 intensive care unit patients with sepsis who were started on insulin infusions, 37.0% (95% CI 34.6-39.5%) were initiated at a blood glucose level below 180 mg/dL, the guideline recommended starting threshold. Conclusion Guideline-concordant insulin infusion initiation was uncommon among patients with sepsis admitted to United States ICUs and was determined in large part by hospital of admission. The degree to which hospitals were guideline-concordant was not associated with mortality.