Background:
Hyperglycemia is directly associated with increased risk for infection, delayed healing, increased morbidity, mortality and increased length of stay following orthopedic surgery. A process was developed to identify these patients pre-operatively to proactively intervene before surgery and more aggressively after surgery to control glucose levels.
Purpose:
Retrospective chart reviews and root cause analysis identified a pattern of patients presenting with post -operative hyperglycemia, which is defined according to operative literature as blood glucose > 200mg/dL post op day 1 and /or day 2. The analysis showed the patients at high risk for post-op hyperglycemia had elevated HbA1C (>8), elevated non-fasting glucose (>180) on pre-operative labs or were glucose intolerant, which was not always known pre-operatively.
A HbA1C is ordered on all patients with a history of diabetes or a glucose >180 on PST lab studies. An Adult Nurse Practitioner (ANP) who is a Certified Diabetes Educator (CDE), started to consult with each patient via phone who presented with HbA1C> 8%. For our total hip and knee replacement patients the medicine hospitalist reviewed all cases with HbA1c > 9% and contacted the patients primary care physician as needed. This information was communicated back to the Surgeon and Anesthesiologist. The Surgeon then decided whether to proceed, cancel or delay the case. If the case proceeded then the hospitalist saw the patent POD #0. The ANP/CDE saw the patient POD#1 if glucose > 200mg/dl. Also, standard postoperative IV fluid changed from D5 ½NS to Ringers Lactate to alleviate postoperative hyperglycemia.
Description:
Hyperglycemic events were monitored and recorded. For March-October 2014 there were 42 patients with at least one hyperglycemic episode out of 794 THR/TKR patients (5.2%). For March- October 2015 15 patients had an episode of hyperglycemia out of 786 THR/TKR patients (1.9%). Overall our patients with glycemic control moved from 94.7% to 98.1%. Also, in the intervention time period there were no cancellations on the day of surgery due to hyperglycemia.
Conclusions:
By having a multi-disciplinary process in place to individualize patient interventions and identify the cause of the hyperglycemia we were able to incrementally improve our glycemic control despite a higher percentage of patients with diabetes in the intervention period (20% in 2014 and 30% in 2105).Many patients were identified as requiring outpatient endocrinology consultation or further education and were referred to our outpatient diabetes wellness program. Although there was time commitment required by our ANP/CDE to make the phone calls, it also decreased the overall number of inpatient referrals to a CDE for uncontrolled hyperglycemia in this population, thus ultimately saving time. We are now extending this program to other orthopedic and general surgery cases.