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Washington State Hospital Association

Partnership for Patients Reducing Surgical Site Infections: Glucose Control Clinical Presentation July 10, 2012. Washington State Hospital Association. Partnership for Patients. 40 – Percent reduction in harm 20 – Percent reduction in readmissions 13 – by 2013. Saving Lives.

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Washington State Hospital Association

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  1. Partnership for Patients Reducing Surgical Site Infections: Glucose Control Clinical Presentation July 10, 2012 Washington State Hospital Association

  2. Partnership for Patients • 40 – Percent reduction in harm • 20 – Percent reduction in readmissions • 13 – by 2013 Saving Lives Presented July 10, 2012 at the WSHA Safe Table: Reduction of SSI

  3. 10 Targeted Strategies Infection Reduction: • Catheter-associated urinary tract infections (CAUTI) • Central line-associated blood stream infections (CLABSI) • Surgical site infections (SSI) • Ventilator-associated pneumonia (VAP) Nursing Care: • Injuries from falls and immobility • Pressure ulcers High Risk: • Adverse drug events • Obstetrical adverse events • Venous thromboembolism or blood clots (VTE) Continuity of Care: 10. Prevention of readmissions Cultural Transformation Leadership Engagement Presented July 10, 2012 at the WSHA Safe Table: Reduction of SSI

  4. Presented July 10, 2012 at the WSHA Safe Table: Reduction of SSI

  5. Rationale for a focus on Glucose to Prevent SSI Presented by E. Patchen Dellinger, M.D.Professor and Vice Chairman, Department of SurgeryChief, Division of General Surgery WSHA Safe Table: Reduction of SSI July 10, 2012

  6. Diabetes, Glucose Control, and SSIsAfter Median Sternotomy Latham. ICHE 2001; 22: 607-12 Presented by E. Patchen Dellinger, M.D.Professor and Vice Chairman, Department of SurgeryChief, Division of General SurgeryWSHA Safe Table: Reduction of SSI July 10, 2012

  7. Hyperglycemia and Risk of SSI after Cardiac Operations • No increased risk:Elevated HgbA1cPreoperative hyperglycemia • Increased risk:Diagnosed diabetesUndiagnosed diabetesPost-op glucose > 200 mg% within 48h Latham. InfContrHospEpidemiol. 2001;22:607 Dellinger. InfContrHospEpidemiol. 2001;22:604 Presented by E. Patchen Dellinger, M.D.Professor and Vice Chairman, Department of SurgeryChief, Division of General SurgeryWSHA Safe Table: Reduction of SSI July 10, 2012

  8. Hyperglycemia and Risk of SSI after Cardiac Operations • Hyperglycemia - doubled risk of SSI • Hyperglycemic: 48% of diabetics 12% of nondiabetics 30% of all patients • 47% of hyperglycemic episodes were in nondiabetics Latham. InfContrHospEpidemiol. 2001;22:607 Dellinger. InfContrHospEpidemiol. 2001;22:604 Presented by E. Patchen Dellinger, M.D.Professor and Vice Chairman, Department of SurgeryChief, Division of General SurgeryWSHA Safe Table: Reduction of SSI July 10, 2012

  9. Deep Sternal SSI and Glucose Zerr. Ann ThoracSurg 1997; 63:356 Presented by E. Patchen Dellinger, M.D.Professor and Vice Chairman, Department of SurgeryChief, Division of General SurgeryWSHA Safe Table: Reduction of SSI July 10, 2012

  10. Glucose Control and Deep Sternal Wound Infections Furnary et al. Ann ThoracSurg 1999:67:352 Presented by E. Patchen Dellinger, M.D.Professor and Vice Chairman, Department of SurgeryChief, Division of General SurgeryWSHA Safe Table: Reduction of SSI July 10, 2012

  11. Glucose Control and Mortality after CABG in 3554 Diabetics Furnary. J ThoracCardiovascSurg 2003;125:1007 Presented by E. Patchen Dellinger, M.D.Professor and Vice Chairman, Department of SurgeryChief, Division of General SurgeryWSHA Safe Table: Reduction of SSI July 10, 2012

  12. Early (48h) Postoperative Glucose Levels and SSI after Vascular Surgery >151 mg% 117-151 mg% 103-117 mg% <103 mg% Vriesendorp. Eur J VascEndovascSurg 2004; 28:520-5 Presented by E. Patchen Dellinger, M.D.Professor and Vice Chairman, Department of SurgeryChief, Division of General SurgeryWSHA Safe Table: Reduction of SSI July 10, 2012

  13. Perioperative Hyperglycemia in Noncardiac Surgical Patients: Does it Increase Postoperative Infections? Postop inf = pneumonia, SSI, UTI, sepsis within 30 d Variables = postop gluc, age, race, diabetes, ASA, emergent, op duration, transfusion Significant:postop gluc > 180 O.R.=2.03 gluc increase of 40 O.R.=1.9 ASA & emergent Ramos. Ann Surg 2008;248: 585–591 Presented by E. Patchen Dellinger, M.D.Professor and Vice Chairman, Department of SurgeryChief, Division of General SurgeryWSHA Safe Table: Reduction of SSI July 10, 2012

  14. Mastectomy, Hyperglycemia, and SSI260 patients, 5 glucose determinations (pre-op, at anesthesia induction, intra-op, in PACU, at 24 hrs) Villar-Compte. AJIC 2008; 36:192-8 Presented by E. Patchen Dellinger, M.D.Professor and Vice Chairman, Department of SurgeryChief, Division of General SurgeryWSHA Safe Table: Reduction of SSI July 10, 2012 Odds Risk FactorRatioC.I. Age > 50 3.7 (1.5-9.2) Pre-Op ChemoRads 2.8 (1.4-5.8) Any gluc> 150 mg% 2.9 (1.2-6.2)

  15. Postop Glucose (within 48h) and SSI Ata. Arch Surg 2010: 145: 858-864 Glucose Presented by E. Patchen Dellinger, M.D.Professor and Vice Chairman, Department of SurgeryChief, Division of General SurgeryWSHA Safe Table: Reduction of SSI July 10, 2012

  16. Postoperative Glucose and Mortality in Noncardiac Surgery Frisch. Diabetes Care. 2010; 33: 1883-8 Presented by E. Patchen Dellinger, M.D.Professor and Vice Chairman, Department of SurgeryChief, Division of General SurgeryWSHA Safe Table: Reduction of SSI July 10, 2012 Hyperglycemia in nondiabetic patients was more dangerous than hyperglycemia in diabetics!

  17. Rabbit 2 Study – SurgeryBasal/Bolus vs Sliding Scale Insulin Umpierrez. Diabetes Care 2011; 34: 256-61 Presented by E. Patchen Dellinger, M.D.Professor and Vice Chairman, Department of SurgeryChief, Division of General SurgeryWSHA Safe Table: Reduction of SSI July 10, 2012 Basal BolusSliding Scalep value Patients 104 107 Mean Fasting 155 167 0.04 Mean Daily 157 176 .001 Readings < 140 53% 31% .001 Wound infections 3 11 .05 Any complication 9 26 .003

  18. SCOAP Data on Perioperative Glucose Levels and Insulin Use SCOAP data courtesy of Sung (Steve) Kwon Presented by E. Patchen Dellinger, M.D.Professor and Vice Chairman, Department of SurgeryChief, Division of General SurgeryWSHA Safe Table: Reduction of SSI July 10, 2012 • 11630 patients from 2005-2010 with • Bariatric operation (5360) • Colectomy (6273) • Who either • Experienced hyperglycemia [glucose > 180] (3383) • Or did not (8247) • During the perioperative period or onPOD 1 or POD 2

  19. SCOAP Data on Perioperative Glucose Levels and Insulin Use SCOAP data courtesy of Sung (Steve) Kwon Presented by E. Patchen Dellinger, M.D.Professor and Vice Chairman, Department of SurgeryChief, Division of General SurgeryWSHA Safe Table: Reduction of SSI July 10, 2012 • Diabetic pts 4098 (35%) • Hyperglycemic 2369 (58%) • Nondiabetic pts 7532 (65%) • Hyperglycemic 1014 (13%) • 30% of all hyperglycemic patients were not diabetic!

  20. Hyperglycemia vs No HyperglycemiaAll Patients All p<0.01 SCOAP data courtesy of Sung (Steve) Kwon Presented by E. Patchen Dellinger, M.D.Professor and Vice Chairman, Department of SurgeryChief, Division of General SurgeryWSHA Safe Table: Reduction of SSI July 10, 2012

  21. Hyperglycemia vs No HyperglycemiaDiabetic Patients * p<0.05 ** p<0.01 SCOAP data courtesy of Sung (Steve) Kwon Presented by E. Patchen Dellinger, M.D.Professor and Vice Chairman, Department of SurgeryChief, Division of General SurgeryWSHA Safe Table: Reduction of SSI July 10, 2012

  22. Hyperglycemia vs No HyperglycemiaNondiabetic Patients All p<0.01 SCOAPdata courtesy of Sung (Steve) Kwon Presented by E. Patchen Dellinger, M.D.Professor and Vice Chairman, Department of SurgeryChief, Division of General SurgeryWSHA Safe Table: Reduction of SSI July 10, 2012

  23. Composite Infection in Hyperglycemic Patients With and Without Use of Insulin SCOAP data courtesy of Sung (Steve) Kwon Presented by E. Patchen Dellinger, M.D.Professor and Vice Chairman, Department of SurgeryChief, Division of General SurgeryWSHA Safe Table: Reduction of SSI July 10, 2012

  24. Operative Reintervention in Hyperglycemic Patients With and Without Use of Insulin SCOAP data courtesy of Sung (Steve) Kwon Presented by E. Patchen Dellinger, M.D.Professor and Vice Chairman, Department of SurgeryChief, Division of General SurgeryWSHA Safe Table: Reduction of SSI July 10, 2012

  25. Mortality in Hyperglycemic Patients With and Without Use of Insulin SCOAP data courtesy of Sung (Steve) Kwon Presented by E. Patchen Dellinger, M.D.Professor and Vice Chairman, Department of SurgeryChief, Division of General SurgeryWSHA Safe Table: Reduction of SSI July 10, 2012

  26. Glucose Levels & SSI Presented by E. Patchen Dellinger, M.D.Professor and Vice Chairman, Department of SurgeryChief, Division of General SurgeryWSHA Safe Table: Reduction of SSI July 10, 2012 • The exact “best” level of glucose control is unknown • High glucose levels unequivocally increase the risk of SSI and other complications • Tight glucose control is tricky • Hypoglycemia increases the risk of morbidity and mortality • But appears quite rarely • 2 main models for effective glycemic control • Basal bolus • Continuous infusion

  27. Glucose Control Algorithms Presented by E. Patchen Dellinger, M.D.Professor and Vice Chairman, Department of SurgeryChief, Division of General SurgeryWSHA Safe Table: Reduction of SSI July 10, 2012 The Rabbit 2 basal bolus protocol is online at http://care.diabetesjournals.org/lookup/suppl/doi:10.2337/dc10-1407/-/DC1 The Society of Hospital Medicine Glycemic Control Resource room contains links to multiple insulin infusion protocols at http://www.hospitalmedicine.org/ResourceRoomRedesign/html/12Clinical_Tools/04_Insulin_OrdersIV.cfm

  28. Rabbit 2 Protocols Presented by E. Patchen Dellinger, M.D.Professor and Vice Chairman, Department of SurgeryChief, Division of General SurgeryWSHA Safe Table: Reduction of SSI July 10, 2012

  29. Rabbit 2 Protocols Presented by E. Patchen Dellinger, M.D.Professor and Vice Chairman, Department of SurgeryChief, Division of General SurgeryWSHA Safe Table: Reduction of SSI July 10, 2012

  30. Rabbit 2 Protocols Presented by E. Patchen Dellinger, M.D.Professor and Vice Chairman, Department of SurgeryChief, Division of General SurgeryWSHA Safe Table: Reduction of SSI July 10, 2012

  31. Rabbit 2 Protocols Presented by E. Patchen Dellinger, M.D.Professor and Vice Chairman, Department of SurgeryChief, Division of General SurgeryWSHA Safe Table: Reduction of SSI July 10, 2012

  32. Rabbit 2 Protocols Presented by E. Patchen Dellinger, M.D.Professor and Vice Chairman, Department of SurgeryChief, Division of General SurgeryWSHA Safe Table: Reduction of SSI July 10, 2012

  33. I.V. Insulin Infusion Protocol Presented by E. Patchen Dellinger, M.D.Professor and Vice Chairman, Department of SurgeryChief, Division of General SurgeryWSHA Safe Table: Reduction of SSI July 10, 2012

  34. I.V. Insulin Infusion Protocol Presented by E. Patchen Dellinger, M.D.Professor and Vice Chairman, Department of SurgeryChief, Division of General SurgeryWSHA Safe Table: Reduction of SSI July 10, 2012

  35. I.V. Insulin Infusion Protocol Presented by E. Patchen Dellinger, M.D.Professor and Vice Chairman, Department of SurgeryChief, Division of General SurgeryWSHA Safe Table: Reduction of SSI July 10, 2012

  36. I.V. Insulin Infusion Protocol Presented by E. Patchen Dellinger, M.D.Professor and Vice Chairman, Department of SurgeryChief, Division of General SurgeryWSHA Safe Table: Reduction of SSI July 10, 2012

  37. I.V. Insulin Infusion Protocol Presented by E. Patchen Dellinger, M.D.Professor and Vice Chairman, Department of SurgeryChief, Division of General SurgeryWSHA Safe Table: Reduction of SSI July 10, 2012

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