Inpatient Diabetes Program Glycemic Team Moses Cone Pre … · Inpatient Diabetes Program Glycemic...

PERIOPERATIVE “SWEET” SUCCESS

Inpatient Diabetes Program Glycemic Team

&

Moses Cone Pre-admission Testing Staff

• Literature shows that perioperative patients with diabetes,

with adequate glycemic control have decreased

complications such as hypoglycemia, hyperglycemia,

ketoacidosis, and other infections. It also helps maintain fluid

and electrolyte balance.

• Inconsistent practices were observed in patients with diabetes

in pre-admission testing (PAT), pre-operatively,

intraoperatively and post-operatively therefore standardized

blood glucose management was necessary

• HgbA1C inconsistently available prior to surgery

• Blood sugars not available during PAT appointment

• There was no distinction between Type 1 and Type 2

diabetes regarding medication management prior to

surgery

• Practice of insulin pump management prior to and during

surgery was inconsistent

• Lack of patient education regarding diabetes management

prior to surgery

• “Guidelines for Diabetes Management” were created based

on a literature review and expert consensus by

endocrinologists, anaesthesiology, and clinical nurse

specialists’ which included:

• Goals of Perioperative Diabetes Management

Avoidance of hypoglycemia and hyperglycemia

Prevention of ketoacidosis

Maintenance of fluid and electrolyte balance

Goal glucose reading between 140-200 mg/dl

• General Guidelines for surgery including: Pre-operative

Evaluation, Perioperative and Postoperative management

strategies.

• “Diabetes Medication Adjustment Guidelines Prior to

Procedure and Surgery” were also created for

standardized medication adjustments/instructions prior to

surgery.

• Collaborative meetings were held with anaesthesia, PAT

Nurses , and the Inpatient Diabetes Program to decide how

these guidelines would be initiated.

• It was decided that a Pilot would be initiated on the MC

campus with 4 PAT nurses to test the process and determine

the volume of diabetes patients and “current state” of

glycemic control.

BACKGROUND

“Current Practice” Prior to Pilot

• A1C ordered on all patients with diabetes.

• Capillary blood glucose (CBG) was checked on all patients at PAT appointment.

• CBG’s were evaluated on day of surgery.

• Assessed volume of patients who had diabetes

Methods:

Phase 1 Pilot (63 patients)

Perioperative management of blood glucose in adults with diabetes mellitus. Up To

Date. Literature review current through: Oct 2014.

University of Washington Medical Center, 2007 “How to Manage your Diabetes

Before and After Surgery”.

• Pilot group of 4 PAT nurses were trained on “Diabetes Medication Adjustment Guidelines” and how to

review with patient’s at PAT appointment.

• Phase 2 of Pilot was planned during a 3 week time period which included: A1C, CBG at PAT appointment,

Assessment of type of diabetes, and when to alert PA (CBG>250 mg/dL)

• RN’s reviewed patient written instructions and informed patients of “Pre-surgery insulin doses” and

diabetes medications based on guidelines.

Out of 257 patients 24.5% had diabetes

71.4% had capillary blood glucoses within the goal range of 71-180 mg/dl

REFERENCES

Next Steps:

• Results of 2 week Pilot were reported back to MD’s, PAT nurses, and collaborative team.

• “How to Manage Diabetes Before and After Surgery” patient education sheet was created and presented to

Cone Health Patient Education Committee for approval

Results

Methods:

Phase 2 Pilot (60 patients)

< 70 mg/dL 71-180 mg/dL 181-250 mg/dL >250 mg/dL

Phase 1 Pilot 3.00% 71% 14.20% 9.50%

Phase 2 Pilot 0 63% 28.30% 8.30%

3.00%

71%

14.20%9.50%

0

63%

28.30%

8.30%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

Capillary Blood Glucose (CBG) at PAT appointment

Phase 1 Pilot Phase 2 Pilot

<7.9% 8.0-10.0% >10.0% A1C not done

Phase 1 Pilot 80% 12.20% 8.20% 22%

Phase 2 Pilot 74% 19% 6.30% 11.30%

80%

12.20%8.20%

22%

74%

19%

6.30%11.30%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

A1C Results at PAT appointment

Phase 1 Pilot Phase 2 Pilot

<70 mg/dL 71-180 mg/dL 181-250 mg/dL >251 mg/dL

Phase 1 Pilot 0 83% 11% 6%

Phase 2 Pilot 1.80% 94% 4% 0%

0

83%

11%6%

1.80%

94%

4%0%

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

CBG results: Day of Surgery

Phase 1 Pilot Phase 2 Pilot

• Phase 1 Pilot (63 pts.) versus Phase 2 pilot (60 pts.)• Phase 1 Pilot- 10 patients excluded - surgery cancellation (6) or no documented

CBG day of surgery (4)

• Phase 2 Pilot- 7 patients excluded- surgery cancellation

• Phase 2 of the Pilot showed an improvement in patient’s blood sugars the

day of surgery with 94% being within goal of (71-180 mg/dL)• There was one hypoglycemic event in the Phase 2 Pilot group on the day of surgery,

however insulin doses were decreased the day prior to surgery (prior to pilot insulin

doses were not reduced the day before surgery)

• RN’s did state that they observed increased time needed to review “ How

to Manage your Diabetes Before and After Surgery” therefore prompting

further discussion with leadership regarding appointment lengths.

• Overall the intervention proved successful and blood glucose levels the

day of surgery improved

• Further, A1C results allow MD’s and RN’s to better assess the patients

glycemic control prior to surgery and identify patients who need further

follow-up with PCP and diabetes education after surgery

Conclusions

Implications and Next Steps

• Revise patient instructions and train PACU RN’s regarding “Management

of Blood Sugars” after surgery

• Move pilot forms/assessment to EPIC environment to improve process

• Consider increasing appointment times in PAT for patients with diabetes

• Broaden scope of project to include other campuses within the health

system

• Consider interview of patients to assess their perception of process

Standardization of Care

Patient Education

Transformational

Leadership

Exemplary

Professional

Practice

Empirical

Outcomes

New

Knowledge,

Innovations and

Improvements