Pharmacist Glycemic Control Team Improves Glycemic Control and Reduces Hospital Readmissions in Non–Critically Ill Surgical Patients

Background:

Perioperative hyperglycemia is a risk factor for increased morbidity and mortality. Improved glycemic control has been demonstrated to reduce surgical site infections and reduce perioperative morbidity and length of stay. However, safe and effective glycemic control in transition from the postanesthesia care unit (PACU) can be limited by expert clinician availability. We implemented and evaluated a protocol‐driven and pharmacist‐staffed glycemic control team (GCT) at the main hospital within a large integrated health maintenance organization. All surgical patients with dysglycemia were eligible, but the team only intervened on a consultation basis. The protocol targeted optimizing glycemic control using intravenous or subcutaneous basal‐bolus dosing of insulin as appropriate. The pharmacists oversaw dosing and arranged nutrition consults and patient education when needed.

Methods:

We evaluated the intervention by selecting patients admitted to the PACU who had 2 or more daily glucose point‐of‐care tests (POCTs) perioperatively during a 12‐month preimplementa‐tion and a 12‐month postimplementation period beginning after a 6‐month ramp‐up period. Our population excluded cardiac surgery patients and critically ill postoperative patients who are directly admitted to our intensive care units. Using this pre–post observational study design, we extracted electronic medical record data to assess process measures of glycemic control and hypoglycemia and outcome measures of utilization. We used multivariate modeling to assess the efficacy of the GCT intervention adjusting for age, sex, race, economic status, Charlson comorbidity, length of stay (LOS), surgery type, and prior 12‐month health care utilization.

Results:

Defining good glycemic control as having capillary blood glucose between 70 and 180 mg/dL (allowing 1 value to fall outside range daily), we demonstrated significant improvements in patient care, as exemplified in the run chart demonstrating postoperative day 1 glycemic control. Overall, the percentage of patients with good glycemic control on postoperative days 1–3 increased from 75.7% pre (n = 1371 patients) to 86.8% post (n = 5253), P < 0.0001, and hypoglycemia (defined as any POCT < 70) was reduced from 9.1% to 4.5%, P < 0.0001. Utilization measures improved including reduced all‐cause 90‐day hospital readmission from 14.9% to 11.1%, P = 0.0006, and 90‐day emergency department (ED) visits from 25.1% to 18.1%, P < 0.0001. Adjusted odds ratio from multivariate modeling demonstrate sustained significant improvements for the glycemic measures and utilization outcome measures as shown in Table 1.

TABLE 1 Multivariate Logistic Regression Analysis of Pre‐ and Postglycemic Control Team Implementation

The glycemic control team ramp‐up period was January–June 2009, with full implementation occurring in July 2009.

Conclusions:

Implementation of a pharmacist team available to manage glycemic control in hospitalized postoperative patients led to safer and better quality of care, as measured by improved glycemic control and less hypoglycemia. We further demonstrated reductions in all‐cause hospital read‐missions, ED visits, and readmissions for wound infection.

Disclosures:

K. Mularski ‐ none; D. Mosen ‐ none; C. Yeh ‐ none; R. Mularski ‐ none; A. Hill ‐none; J. Bains ‐ none