A wise nurse can manage a paper protocol but prefers intelligent technology

We were surprised to read the letter "Tight glycaemic control: intelligent technology or a nurse-wise strategy?" by de Graaff and colleagues [1]. In this letter, the use of complex protocols for tight glucose control is questioned, and a strategy as used in Leuven is proposed: based on nurses' experience, guided with only a few very simple guidelines.

Glucose control is not simple but complex. This complexity is underscored by major problems that have been encountered with respect to safety and efficiency. Many factors are known to influence glucose control. Standardizing glucose control has been found to improve both safety and the efficiency of glucose control [2]. Moreover, results obtained with unstandardized treatment protocols as proposed by de Graaff et al. should be interpreted with great caution, as the exact characteristics of the therapy are unknown. We agree with de Graaff et al. that paper protocols can become too complex and may result in bad compliance, efficiency and safety.

Computer protocols are generally easy to follow and require fewer glucose measurements than paper-based protocols [3–5]. In our own three-year experience, nurses – both novice and experienced – are very pleased with the efficient process a computer provides. Still, we also value wise nurses and allow our computer protocol to be overridden when needed.

Abandoning advanced standardized therapy in favor of relying on human decision-making would clearly be a step backward in our view. The current "5 million lives campaign" by the Institute for Healthcare Improvement calls for a 50% reduction of harm related to high-alert medications (including insulin) focusing on standardization strategies to reduce the chance of human error [6]. In our opinion, a computer program recommending an insulin level, and seeing to it that glucose gets checked in time is the most standardized, effortless, safe and efficient form of glucose control currently available.