Improvements in Post-Operative Glycemic Control in Cardiac Surgery Patients

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Primary Author:</td>
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Eric Hadhazy, MS</td>
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Co-Principal Investigators/Collaborators:</td>
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<p>Salome Hoorzuk, RN, Julie Shinn, RN, Kathy Seppala, RN, Meital Gabay, PhD, John Shepard, MHA, Lawrence Cai, Jeff Choi, Debora Lin, PhD, Sanchay Gupta, Christina Loh, PhD, Deborah Rodrigues, RN, Allison Reilly, NP, Marina Basina, MD, Charles Hill, MD</p>
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Organization:</td>
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<p>Stanford Hospital & Clinics</p>
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Abstract</h2>
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Purpose</h3>
<p>To reach and sustain 100% compliance with the changes in the SCIP-4 measure effective January 2014. </p>
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Background</h3>
<p>Post-operative glycemic control is associated with improved patient outcomes and decreased complications. Further evidence supports tighter regulation of glucose management in postop cardiac surgery patients. The Surgical Care Improvement Project-4 (SCIP-4) measure was modified to reflect these best-practice guidelines effective January 2014. Patients now require a minimum of two blood glucose values < 180 mg/dL 18 to 24 hours after Anesthesia End Time. Previous SCIP-4 measure required a single blood glucose < 200 mg/dL at 6:00 AM on postop day 1 or 2 with Surgery End Date being postop day 0. </p>
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Materials & Methods</h3>
<p>Formed an interdisciplinary team in September 2013 to evaluate current state, identify gaps, and implement countermeasures prior to January 2014. Prospective analysis using both 2013 and 2014 SCIP-4 methodologies from September 2013 to December 2013 was conducted. Compliance in September, October, November, and December using 2013 SCIP-4 and 2014 SCIP-4 methodology was 100% 80%, 100%, and 100%, and 78%, 69%, 82%, and 90%, respectively. Root cause analysis was used on cases that did not satisfy 2014 SCIP-4 measurement. Interviews of front-line staff, observations, literature review, and comparison of similar institutional practices was conducted. </p>
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Results</h3>
<p>Analysis showed diet and transition from intravenous (IV) insulin to subcutaneous (SC) insulin was responsible for 86% of fallouts using 2014 SCIP-4 methodology. Recommendations included patients remain on 24 hour postop IV insulin, remain NPO for 24 hours, and specific glycemic education be given to CVICU residents. Creation of an IV insulin calculator to automate the current IV insulin protocol was developed. Since implementation of recommendations, SCIP-4 compliance has been 100% through March 2014. </p>
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Conclusion</h3>
<p>Keeping patients NPO and on IV insulin for 24 hours following cardiac surgery with the addition of glycemic education and utilizing an IV insulin calculator is effective at tightly regulating glucose and achieving 100% SCIP-4 compliance. </p>
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Bibliography</h3>
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Latham R, Lancaster AD, Covington JF, etal. The association of diabetes and glucose control with surgical-site infections among cardiothoracic surgery patients. Infect Control Hosp Epidemiol. 2001 Oct;22(10):607-612. PMID: 11776345.</li>
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Lazar H, McDonnell M, Chipkin S, Furnary A, Engelman R, Sadhu A, Bridges C, Haan C, Svedjeholm R, Taegtmeyer H, Shemin R. The Society of Thoracic Surgeons practice guideline series: Blood glucose management during adult cardiac surgery. Ann Thorac Surg. 2009;87;663-669.</li>
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Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med. 2001 Nov 8;345(19):1359-1367. PMID: 11794168.</li>
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Zerr KJ, Furnary AP, Grunkemeier GL, et al. Glucose control lowers the risk of wound infection in diabetics after open heart operations. Ann Thorac Surg. 1997 Feb;63(2):356-361. PMID: 9033300.</li>
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<p>© Improvement Science Research Network, 2012</p>
<p>The ISRN published this as received and with permission from the author(s).</p>