Prevention of SSI- Applying the Glucose Control Component

Sharing the HHS Experience

Dr. Richard McLean, MD, FRCP(C)Emily Christoffersen RN, BScNRhonda Smith RN, BScN, MEd

SSI project at HHS

• Population: elective abdominal surgery patients at one site

• Bundle of three strategies: glucose control, maintenance of patient temperature, optimal antibiotic delivery

• Dates: October 2004- present

Why Glucose?

• Diabetes an independent risk factor for infection in Cardiac Surgery Population [Harrington et a Infection Control and Hospital Epidemiology 2004]

• New Hyperglycemia marker of poor clinical outcome: increased mortality/LOS/ICU Admission [Umpierrez J Clin Endocrinol Metab 2002]

• Early Postoperative Hyperglycemia increases risk of nosocomial infection 5.9 fold [Pomposelli et al. Journal of Parenteral and Enteral Nutrition 1998]

• Glucose control improves outcome in ICU population and in Cardiac Surgery [Van Den Berghe et al. NEJM 2001, Furnary et al Ann Thorac Surg 1999]

Change Concept: Develop your team

• Identify project leaders (physician champion)

• Outline roles• Engage frontline clinicians • Involve a multidisciplinary team

(physicians/nurses/pharmacy)• Include members from all areas of care-

preop, OR, PACU, post op units

Need users of process to make improvements- helps with uptake

Change Concept: Create vision and commitment

• Present literature about glucose control and SSI

• Identify goals for caring for surgical patients re. glucose control

Helps identify rationale- makes it real

Change concept: Outline current reality

• Determine how currently monitor and treat glucose levels in surgical patients

• Map-out processes• Involve all parts of care

[preop clinic/same day surgery/operating room/PACU/Ward/ICU]

Identifies where the group should start- what works well? what needs to change?

Change Concept:Design new processes

• Identify processes for both monitoring and treatment

• Developed preprinted orders• Developed standard documentation to

follow through care process• Use rapid tests of change- plan, do, study,

act• Simulate new process before

implementation– First run with team involved in develpment– 2nd run “naive” team

Build process with an eye on sustainability

New Process at HHS- Perioperative Glucose Control

• All patients have CBG drawn in pre op clinic• Diabetics, and anyone with a random CBG

>11 mmol will be flagged to have a repeat CBG day of surgery

• These patients need CBG every two hours • CBG >11 in SDS or anytime during

operative period- notify anaesthesiologist or surgeon

• Transition to new subcutaneous insulin protocol post operatively as needed

What we’ve learned

• Intervention needs to be tailored to patient population– What is the incidence of diabetes in the patient

population?– Need a critical mass of patients to support insulin

infusions in perioperative period

• Be flexible- even if a new process is developed, be willing to change before full implementation

• Must have lots of energetic, committed clinicians involved

• Start developing preprinted orders as soon as possible