SCOAP Community Speaks Up: Glycemic Control

Colleagues at St. Francis Medical Center have asked “What are effective strategies to improve our approach to glycemic control postoperatively?” 

This is a very timely question. SCOAP has been tracking four aspects of glycemic control in colorectal surgeries among diabetic patients:  1) Perioperative Glucose Measurement; 2) Insulin Given during the Perioperative Period; 3) Controlled Glucose within the 48 hours Postoperatively;  and most recently, 4) Avoidance  of Low Blood Sugar among Diabetics.  Our most recent data reports for the 2nd quarter of 2010 show that the top performing hospitals in Washington State achieve 100% for measuring blood glucose and are at 85.4% for use of insulin in the perioperative period. Concerns about the unintended consequence of hypoglycemia are allayed by the data that show low blood sugars are avoided in 94.8% of cases.  But data from even the best performing SCOAP hospitals puts front and center that it is a struggle to achieve consistent glycemic control postoperatively. The current benchmark for this metric shows that  only 72.7% of diabetics are anything close to controlled (glucose<200) in the two days following their surgery. This component of glycemic control remains a challenging aspect of surgical care and an area that the SCOAP community is ready to hit head on.   

Why do we want to avoid elevated post-operative blood glucose? 

There is substantial evidence that elevated glucose levels in hospitalized patients are associated with increased morbidity and mortality.  This holds true regardless of the reason for hyperglycemia.  Several observational studies of medical and surgical patients have shown a strong association between hyperglycemia and adverse outcomes such as prolonged hospital stay, infection, disability after discharge from the hospital, and death[1].   Ramos et al.[2]  conducted a retrospective study of 995 patients who underwent general or vascular surgery and found that elevated post-operative hyperglycemia increased the risk of post-operative infection by 30% with every 40-point increase from euglycemia (<110 mg/dl). Hyperglycemia is also associated with increased rates of infection in hepato-biliary-pancreatic cancer patients[3], the orthopedic hospital setting[4], hepatic surgery,[5] spinal surgery[6], liver transplantation[7], mastectomy[8], cardiac surgery[9], infraninguinal vascular surgery[10], and hospitalized patients in general[11]. 

Does improving patients’ blood glucose control improve morbidity and mortality?  Are there risks of tight glucose control?   

Interventions designed to reduce blood glucose levels have resulted in improved outcomes in many studies and varied hospital populations, with the best data coming from cardiac surgery populations, and it is clear that uncontrolled blood glucose levels have a negative effect on patient outcomes[12].  Furnary et al.[13] conducted a prospective interventional study of 3554 CABG patients and found that insulin drip protocols improved in-hospital mortality in diabetic patients.  Similar improvements in morbidity and mortality were also found in studies of other open heart operations[14] in the ICU population[15], [16] and acute MI[17].  There is no reason to believe that white blood cells function differently when bathed in the hyperglycemic blood of a patient having open heart or open abdomen surgery. Others have suggested that hyperglycemia after surgery is a normal stress response, but there are little data to suggest that glucose control in a more normal range of 125 to 200 is a negative[18].  However, there is also recent evidence that very tight glucose control (81-108 mg/dL) may not improve outcomes when compared to more conventional blood glucose management (<180 mg/dL).  In fact, a recent large RCT by Finfer et al.[19] found that in both surgical and medical ICU patients, 90-day mortality was significantly higher in the tightly controlled group versus the conventionally controlled group.  There were significantly more deaths from cardiovascular causes in the tightly controlled group (81-108 mg/dL) as well as a higher prevalence of severe hypoglycemia.  SCOAP is identifying blood sugars over 200 mg/dL, because widely accepted “targets” for glycemic control under 200 have been selected without much risk of hypoglycemic events. 

Given the evidence above, what are the recommended glucose targets? 

The AACE/ADA recommendations[20] are: 

  • A target of 140-180 mg/dl is preferable for MOST patients. 
  • A target of 110-140 mg/dl may be appropriate in SELECTED patients (patients treated in sites with extensive experience and appropriate support – perhaps CABG surgical patients, sites with low rates of hypoglycemia, patients on TPN, etc). 
  • A target > 180 mg/d/ or < 110 mg/dl is NOT recommended.

What strategies have worked at other hospitals to improve post-operative glucose control? 

Hospitals that are successful in their glycemic control efforts have abandoned sliding scale insulin in the face of multiple studies that have demonstrated that this approach is ineffective[21].  They assess each patient for their risk for hyperglycemia by looking at their previous level of control (as represented by HbA1C level), current dietary intake, and the severity of their illness.  Many hospitals use insulin infusions in the immediate postoperative period and then transition the patient to subcutaneous administration.  They have developed insulin protocols with algorithms that use basal insulin (to inhibit hepatic gluconeogenesis), nutritional insulin (to facilitate mealtime glucose metabolism), and correctional insulin (to provide real time adjustment of insulin dosage based on the patient’s insulin sensitivity). 

Southwest Washington Medical Center in Vancouver, WA, recently won a Best Practice Award for their Glycemic Control Program.  They formed a team with a full-time dedicated diabetes pharmacist, a certified diabetic educator, and a physician for oversight.  The pharmacist is responsible for managing the medication therapy and monitoring of glucose levels for hospitalized patients with diabetes or hyperglycemia, and the diabetes educator provides patient education.  As a result of this program, the average glucose level decreased from 165.4 mg/dL in January 2006 to 148.5 mg/dL in August 2007.[22] 

Other hospitals have piloted and tested different models and methods of glycemic control[23].  Barnes-Jewish Hospital (St. Louis, MO) compared a physician-initiated insulin intervention (without a developed protocol or blood glucose target) with a nurse-driven insulin protocol with a target of 80-150 mg/dL for patients in the Surgical ICU.  They found that the nurse-driven protocol was more timely and effective in decreasing patients’ blood glucose than the physician model.  

Both Croze-Chester Keystone Medical Center (Philadelphia, PA) and Central DuPage Hospital (Winfield, IL) received benchmarking awards for reducing their mean blood glucose levels in the ICU[24].  Both hospitals formed multidisciplinary teams including nurses, pharmacists, and physicians to address the problem of hyperglycemia in their ICUs.  They set targets in the 85-120 mg/dL range and credit regular meetings, daily discussion during rounds, and education and coordination among their nurses, pharmacists, and physicians to their success. 

How do I get started to improve these metrics at my hospital? 

Unlike many aspects of surgical care, glycemic control is a systems issue involving multiple disciplines and care processes.  It’s a team sport!  A common approach is to start by creating a Glucose Control Team that includes hospitalists, endocrinologists, critical care physicians, surgeons or other physician leadership, QI staff and process owners, and frontline personnel such as nurses, pharmacists or other interested staff.  Assess target areas for performance improvement to determine if glucose testing is adequate – non-testing of patients in the operating room or on the floor may skew results and hide the extent of the problem.  SCOAP recommends that all patients with diabetes have an operating room blood sugar and then at least fasting blood sugars on days 1 and 2 (more if the blood sugar is elevated).  Additional testing is probably a good idea for all patients, but there is limited evidence to guide the question of testing frequency absent elevations in fasting levels. Determine reasons for underperformance – to start, look at whether improper glucose control medication was ordered, if improper adjustments of medications were made based on glucose values, and if protocols and algorithms wereadequate. 

 Once the team is formed and preliminary data is gathered, look at data from patients who were not adequately controlled (glucose > 200 mg on POD 1 or 2) if possible while they are still in the hospital so their care can be improved in real time. Chart reviews or automated reports can tease out: 

 

  • What medications were ordered.
  • Whether insulin was ordered as a drip or subcutaneous.
  • Whether insulin was administered properly per ordered algorithm (were adjustments in insulin dose made based on increased or decreased blood glucose values).
  • Timing of glucose measurements and meals.
  • Other blood sugar values to see if these are isolated incidences or if there are multiple elevated values for any given patient.
  • Other data based on feedback from Glucose Control Team that may be specific to your hospital.

  

With your Glucose Control Team, review all available hospital data and set specific aims and goals for glycemic control at your hospital: 

 

  • Choose specific glucose targets.
  • Set timelines for improvement.
  • Decide when/how you will monitor and assess these improvements (quarterly SCOAP reports provide timely, benchmarked data to track progress).

  

Other ideas for your Glucose Control Team: 

 

  1. Standardized order sets
  2. Create algorithms, policies and protocols, for examples and other glycemic control resources see:  http://www.hospitalmedicine.org/ResourceRoomRedesign/GlycemicControl.cfm
  3. Provide education to hospital personnel and to patients
  4. Reassess quarterly using SCOAP data

 As you can see, SCOAP is not simply about tracking metrics or “dinging” surgeons – it’s about changing individual and system behavior so we can have fewer infections in our patients and better outcomes overall.  We need your help:  as surgeons you need to demand that your hospitals take glycemic control seriously, and you need to be engaged as they try to address glycemic control.  They are looking to you for engagement in this and want partners.  Remember also that the SCOAP checklist calls out the step on getting a blood sugar on patients with diabetes and starting insulin. This is your opportunity to make sure the system is working for your patients.

 

 SCOAP surgeons know that if we do this it will be better than if it’s done to us.  Thanks for all you do to make SCOAP a success and creating the future of surgical quality improvement. 

References: 

 


 

[1] Clement S., Braithwaite S.S., Magee M.F., Ahmann, A., Smith, E.P., Schafer, R.G., and Hirsch, I.B., Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27:553-591. 

  

[2] Ramos, M., Khalpey, Z., Lipsitz, S., Steinberg, J., Panizales, M.T., Zinner, M. and Rogers, S.O., Relationship of perioperative hyperglycemia and postoperative infections in patients who undergo general and vascular surgery. Ann Surg, 2008. 248(4): p. 585-91. 

  

[3] Ambiru, S., Kato, A., Kimura, F., Shimizu, H., Yoshidome, H., Otsuka, M. and Miyazaki, M., Poor postoperative blood glucose control increases surgical site infections after surgery for hepato-biliary-pancreatic cancer: a prospective study in a high-volume institute in Japan. J Hosp Infect, 2008. 68(3): p. 230-3. 

  

[4] Lamloum, S.M., Mobasher, L.A., Karar, A.H., Basiony, L., Abdallah, T.H., Al-Saleh, A.I. and Al-Shamali, N.A., Relationship between postoperative infectious complications and glycemic control for diabetic patients in an orthopedic hospital in Kuwait. Med Princ Pract, 2009. 18(6): p. 447-52. 

  

[5] Okabayashi, T., Nishimori, I., Yamashita, K., Sugimoto, T., Yatabe, T., Maeda, H., Kobayashi, M. and Hanazaki, K., Risk factors and predictors for surgical site infection after hepatic resection. J Hosp Infect, 2009. 73(1): p. 47-53. 

  

[6] Olsen, M.A., Nepple, J.J., Riew, K.D., Lenke, L.G., Bridwell, K.H., Mayfield, J. and Fraser, V.J., Risk factors for surgical site infection following orthopaedic spinal operations. J Bone Joint Surg Am, 2008. 90(1): p. 62-9. 

  

[7] Park, C., Hsu, C., Neelakanta, G., Nourmand, H., Braunfeld, M., Wray, C., Steadman, R.H., Hu, K.Q., Cheng, R.T. and Xia, V.W., Severe intraoperative hyperglycemia is independently associated with surgical site infection after liver transplantation. Transplantation, 2009. 87(7): p. 1031-6. 

  

[8] Vilar-Compte, D., Alvarez de Iturbe, I., Martin-Onraet, A., Perez-Amador, M., Sanchez-Hernandez, C. and Volkow, P., Hyperglycemia as a risk factor for surgical site infections in patients undergoing mastectomy. Am J Infect Control, 2008. 36(3): p. 192-8. 

  

[9] Golden, S.H., Peart-Vigilance, C., Kao, W.H., Brancatai, F.L., Perioperative glycemic conrol and the risk of infectious complications in a cohort of adults with diabetes. Diabetes Care 1999; 22: 1408– 1414 

  

[10] Vriesendorp, T.M., Morelis, Q.J., Devries, J.H., Legemate, D.A. and Hoekstra, J.B., Early post-operative glucose levels are an independent risk factor for infection after peripheral vascular surgery. A retrospective study. Eur J Vasc Endovasc Surg, 2004. 28(5): p. 520-5. 

  

[11] Bruno, A., Gregori, D., Caropreso, A., Lazzarato, F., Petrinco, M., Pagano, E., Normal glucose values are associated with a lower risk of mortality in hospitalized patients. Diabetes Care 2008; 31: 2209– 2210 

  

[12] American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on Inpatient Glycemic Control Diabetes Care. 2009 June;32(6):1119-1131. (published online May 8, 2009).Consensus: Inpatient Hyperglycemia, Endocr Pract. 2009;15(No. 4):1-17. 

  

[13] Furnary, A.P., Gao, G., Grunkemeier, G.L., Wu, Y., Zerr, K.J., Bookin, S.O., Floten, H.S. and Starr, A., Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg, 2003. 125(5): p. 1007-21. 

  

[14] Zerr, K.J., Furnary, A.P., Grunkemeier, G.L., Bookin, S., Kanhere, V. and Starr, A., Glucose control lowers the risk of wound infection in diabetics after open heart operations. Ann Thorac Surg, 1997. 63(2): p. 356-61 

  

[15] van den Berghe, G., Wouters, P., Weekers, F., Verwaest, C., Bruyninckx, F., Schetz, M., Vlasselaers, D., Ferdinande, P., Lauwers, P., Bouillon, R.,  Intensive insulin therapy in critically ill patients. N Engl J Med 2001; 345: 1359– 1367 

  

[16] Krinsley J.S.,  Effect of intensive glucose management protocol on the mortality of critically ill adult patients. Mayo Clin Proc 2004; 79: 992– 1000 

  

[17] Malmberg K.,  Prospective randomised study of intensive insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus. BMJ 1997; 314: 1512– 1515 

  

[18] Clement S., Braithwaite S.S., Magee M.F., Ahmann, A., Smith, E.P., Schafer, R.G., and Hirsch, I.B., Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27:553-591. 

  

[19] Finfer, S., Chittock, D.R., Su, S.Y., Blair, D., Foster, D., Dhingra, V., Bellomo, R., Cook, D., Dodek, P., Henderson, W.R., Hébert, P.C., Heritier, S., Heyland, D.K., McArthur, C., McDonald, E., Mitchell, I., Myburgh, J.A., Norton, R., Potter, J., Robinson, B.G., Ronco, J.J., Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009; 360: 1283– 1297 

  

[20] Workbook for Improvement “Improving Glycemic Control. Preventing Hypoglycemia and Optimizing Care of the Inpatient with Hyperglycemia and Diabetes” Retrieved 4/22/2010 from http://www.hospitalmedicine.org/ResourceRoomRedesign/GlycemicControl.cfm

  

[21] Nau  KC, Lorenzetti  RC, Cucuzzella  M, Devine  T, Kline  J.  Glycemic control in hospitalized patients not in intensive care: beyond sliding-scale insulin.  Am Fam Physician.  2010;81(9):1130–1135. 

  

[22] Finneman, L., Sherington, S., Hogness, C., Wilson, K., Thorsgard, E.,  Parker, R., Gaudette, K., Improving Glycemic Control in an Inpatient Setting Through Implementation of a Glycemic Control Team  Retrieved April 22, 2010 from http://www.ashpadvantage.com/bestpractices/2007_papers/finneman.htm 

  

[23] Taylor, B.E., Schallom, M.E., Sona, C.S., Buchman, T.G., Boyle, W.A., Mazuski, J.E., Schuerer, D.E., Thomas, J.M., Kaiser, C., Huey, W.Y., Ward, M.R., Zack, J.E., Coopersmith, C.M.,  Efficacy and safety if an insulin infusion protocol in a surgical ICU.  Journal of the American College of Surgeons, 2006; 202(1) 

  

[24] Blood glucose Benchmarking Results in US Hospital ICUS for 2008 Announced.  Retrieved 4/26/2010 from: http://www.rals.com/RALS-Report.html

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1 Response to “SCOAP Community Speaks Up: Glycemic Control”


  1. 1 John Murphy November 9, 2010 at 7:02 am

    I would love to talk with the author of this article but I find no one listed. Can you put me in touch with that person? Thank you.


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