Faculty Collaboration Database

A Perioperative Systems Design to Improve Intraoperative Glucose Monitoring Is Associated with a Reduction in Surgical Site Infections in a Diabetic Patient Population. Anesthesiology 2017 Mar;126(3):431-440

Date

01/21/2017

Pubmed ID

28106608

DOI

10.1097/ALN.0000000000001516

Scopus ID

2-s2.0-85009963072 (requires institutional sign-in at Scopus site)   42 Citations

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.

Author List

Ehrenfeld JM, Wanderer JP, Terekhov M, Rothman BS, Sandberg WS

Author

Jesse Ehrenfeld MD, MPH Sr Associate Dean, Director, Professor in the Advancing a Healthier Wisconsin Endowment department at Medical College of Wisconsin

MESH terms used to index this publication - Major topics in bold

Blood Glucose
Diabetes Mellitus
Female
Humans
Hypoglycemic Agents
Insulin
Male
Middle Aged
Monitoring, Intraoperative
Perioperative Care
Reproducibility of Results
Surgical Wound Infection