A Perioperative Systems Design to Improve Intraoperative Glucose Monitoring Is Associated with a Reduction in Surgical Site Infections in a Diabetic Patient Population

Abstract

Background Diabetic patients receiving insulin should have periodic intraoperative glucose measurement. The authors conducted a care redesign effort to improve intraoperative glucose monitoring. Methods With approval from Vanderbilt University Human Research Protection Program (Nashville, Tennessee), the authors created an automatic system to identify diabetic patients, detect insulin administration, check for recent glucose measurement, and remind clinicians to check intraoperative glucose. Interrupted time series and propensity score matching were used to quantify pre- and postintervention impact on outcomes. Chi-square/likelihood ratio tests were used to compare surgical site infections at patient follow-up. Results The authors analyzed 15,895 cases (3,994 preintervention and 11,901 postintervention; similar patient characteristics between groups). Intraoperative glucose monitoring rose from 61.6 to 87.3% in cases after intervention (P = 0.0001). Recovery room entry hyperglycemia (fraction of initial postoperative glucose readings greater than 250) fell from 11.0 to 7.2% after intervention (P = 0.0019), while hypoglycemia (fraction of initial postoperative glucose readings less than 75) was unchanged (0.6 vs. 0.9%; P = 0.2155). Eighty-seven percent of patients had follow-up care. After intervention the unadjusted surgical site infection rate fell from 1.5 to 1.0% (P = 0.0061), a 55.4% relative risk reduction. Interrupted time series analysis confirmed a statistically significant surgical site infection rate reduction (P = 0.01). Propensity score matching to adjust for confounders generated a cohort of 7,604 well-matched patients and confirmed a statistically significant surgical site infection rate reduction (P = 0.02). Conclusions Anesthesiologists add healthcare value by improving perioperative systems. The authors leveraged the one-time cost of programming to improve reliability of intraoperative glucose management and observed improved glucose monitoring, increased insulin administration, reduced recovery room hyperglycemia, and fewer surgical site infections. Their analysis is limited by its applied quasiexperimental design.

CYP2D6 Genotype-guided Metoprolol Therapy in Cardiac Surgery Patients: Rationale and Design of the Pharmacogenetic-guided Metoprolol Management for Postoperative Atrial Fibrillation in Cardiac Surgery (PREEMPTIVE) Pilot Study

“…Key elements of a successful implementation of CDS are present, including the comprehensive engagement and training of end users, optimization of the user experience with the software, adequate and persistent technical support, and commitment from departmental and hospital stakeholders and leadership. 31,32 Several different study designs were considered for this pilot study. Given the allele frequencies of the different CYP2D6 genotypes, and the feasibility and cost of conducting a pharmacogenetic pilot study, the authors have opted to use a one-arm Bayesian adaptive design trial.…”

Liraglutide for perioperative management of hyperglycaemia in cardiac surgery patients: a multicentre randomized superiority trial

“…Besides the intervention group in this study, glycaemic control in the placebo group was also quite good, with a mean intraoperative BG of 7.0 mmol/L and only 4% of patients experiencing hyperglycaemia >11.0 mmol/L. It is probable that the glycaemic control in the placebo group was positively influenced by a clinical trial effect, because outside of clinical trials, non‐compliance with insulin protocols results in poorer glycaemic control . Considering the relatively modest contrast in glycaemic control, it is perhaps not surprising that we found no difference in any of the composite endpoints of complications, whereas studies with interventions resulting in larger differences in BG concentrations did report significant differences in complications .…”

“…It is probable that the glycaemic control in the placebo group was positively influenced by a clinical trial effect, because outside of clinical trials, non-compliance with insulin protocols results in poorer glycaemic control. 4,22 Considering the relatively modest contrast in glycaemic control, it is perhaps not surprising that we found no difference in any of the composite endpoints of complications, whereas studies with interventions resulting in larger differences in BG concentrations did report significant differences in complications. 1,26,27 Importantly, this trial was not powered to find a reduction in complications.…”

“…The Joint Commission on Accreditation of Healthcare Organizations marked insulin as one of five high-alert medications. 22 Although its use is directly correlated to hypoglycaemia, so far there were no alternatives to insulin for the treatment of perioperative hyperglycaemia. 2 With hyperglycaemia and hypoglycaemia both having been linked to postoperative complications, 23 an impasse exists.…”

Intraoperative hyperglycemia is independently associated with infectious complications after non-cardiac surgery

“…Two recent randomized controlled trials focused on vascular surgery patients have had conflicting results, with one observing decreased morbidity and mortality associated with tight glucose control, while the other trial failed to observe a statistically significant difference [ 16 – 18 ]. Recently, a prospective study designed to electronically remind clinicians intraoperatively to recheck glucose values on diabetic patients without any specific glucose treatment goals documented a reduced relative risk reduction of 55.4% in surgical site infections [ 19 ]. However, no target glucose ranges for normoglycemia were required and the actual achieved intraoperative glucose values were not reported.…”