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

Washington State Hospital Association

Partnership for PatientsReducing Surgical Site Infections:

Glucose Control

Clinical PresentationJuly 10, 2012

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

10 Targeted StrategiesInfection Reduction:1. Catheter-associated urinary tract infections (CAUTI)2. Central line-associated blood stream infections (CLABSI)3. Surgical site infections (SSI)4. Ventilator-associated pneumonia (VAP)Nursing Care:5. Injuries from falls and immobility6. Pressure ulcersHigh Risk:7. Adverse drug events8. Obstetrical adverse events9. 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

Washington State Surgical Site Infection Rate: Jan 2010- Sep 2011

Data taken from the National Healthcare Safety Network and Washington State Hospital Association's Quality Benchmarking System.

July 2010August 2010

September 2010October 2010November 2010December 2010January 2011February 2011

March 2011April 2011May 2011June 2011July 2011August 2011

September 2011

0.0

0.5

1.0

1.5

2.0

2.5

3.0

Infections/100 Procedures

Surgical Site Infections/100 Procedures by Procedure Type

ProcedureType

Cardiac Hip & Knee Hysterectomy Presented July 10, 2012 at the WSHA Safe Table: Reduction of SSI

Rationale for a focus on Glucose to Prevent SSI

Presented by E. Patchen Dellinger, M.D.Professor and Vice Chairman, Department of Surgery

Chief, Division of General Surgery

WSHA Safe Table: Reduction of SSI July 10, 2012

Diabetes, Glucose Control, and SSIsAfter Median Sternotomy

0

5

10

15

20

<200 200-249 250-299 >300

% In

fect

ions

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

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. Inf Contr Hosp Epidemiol. 2001;22:607Dellinger. Inf Contr Hosp Epidemiol. 2001;22:604


Hyperglycemia and Risk of SSI after Cardiac Operations

• Hyperglycemia - doubled risk of SSI• Hyperglycemic:

48% of diabetics12% of nondiabetics30% of all patients

• 47% of hyperglycemic episodes were in nondiabetics Latham. Inf Contr Hosp Epidemiol. 2001;22:607

Dellinger. Inf Contr Hosp Epidemiol. 2001;22:604


Deep Sternal SSI and Glucose

0

1

2

3

4

5

6

7

8

100-150 150-200 200-250 250-300

Day 1 Glucose (mg%)

% D

eep

Ste

rnal

Infe

ctio

n

Zerr. Ann Thorac Surg 1997; 63:356


Furnary et al. Ann Thorac Surg 1999:67:352

Glucose Control and Deep Sternal Wound Infections


Glucose Control and Mortality after CABG in 3554 Diabetics

Furnary. J Thorac Cardiovasc Surg 2003;125:1007


Early (48h) Postoperative Glucose Levels and SSI after Vascular Surgery

Vriesendorp. Eur J Vasc Endovasc Surg 2004; 28:520-5

<103 mg%

103-117 mg%

117-151 mg%

>151 mg%


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.=2.03gluc increase of 40 O.R.=1.9ASA & emergent

Ramos. Ann Surg 2008;248: 585–591


Mastectomy, Hyperglycemia, and SSI

260 patients, 5 glucose determinations (pre-op, at anesthesia induction, intra-op, in PACU, at 24 hrs)

Odds•Risk Factor Ratio C.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)

Villar-Compte. AJIC 2008; 36:192-8


Postop Glucose (within 48h) and SSI

0

2

4

6

8

10

12

14

< 110 111-140 141-180 181-220 > 220

Relative Risk

Ata. Arch Surg 2010: 145: 858-864

Glucose


Postoperative Glucose and Mortality in Noncardiac Surgery

Hyperglycemia in nondiabetic patients

was more dangerous than

hyperglycemia in diabetics!Frisch. Diabetes Care. 2010; 33: 1883-8


Rabbit 2 Study – SurgeryBasal/Bolus vs Sliding Scale Insulin

Basal Bolus Sliding Scale p valuePatients 104 107Mean Fasting 155 167 0.04Mean Daily 157 176 .001Readings < 140 53% 31% .001Wound infections 3 11 .05Any complication 9 26 .003

Umpierrez. Diabetes Care 2011; 34: 256-61


SCOAP Data on Perioperative Glucose Levels and Insulin Use

• 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

SCOAP data courtesy of Sung (Steve) Kwon


SCOAP Data on Perioperative Glucose Levels and Insulin Use

• Diabetic pts 4098 (35%) Hyperglycemic 2369

(58%)

• Nondiabetic pts 7532 (65%) Hyperglycemic 1014

(13%)

•30% of all hyperglycemic patients were not diabetic!



Hyperglycemia vs No HyperglycemiaAll Patients

02468

10121416

All Pts Bariatric Colectomy

Normal

Gluc>180

All p<0.01



Hyperglycemia vs No HyperglycemiaDiabetic Patients

0

2

4

6

8

10

12

14

Both Ops Bariatric Colectomy

Normal

Gluc>180**

* p<0.05** p<0.01



Hyperglycemia vs No HyperglycemiaNondiabetic Patients

0

5

10

15

20

All Pts Bariatric Colectomy

Normal

Gluc>180

All p<0.01



Composite Infection in Hyperglycemic Patients With and Without Use of Insulin

0

0.5

1

1.5

2

2.5

No Insulin Insulin

Odds Ratios



Operative Reintervention in Hyperglycemic Patients With and Without Use of Insulin

0

0.5

1

1.5

2

2.5

No Insulin Insulin

Odds Ratios



Mortality in Hyperglycemic Patients With and Without Use of Insulin

00.5

11.5

22.5

33.5

No Insulin Insulin

Odds Ratios



Glucose Levels & SSI

• 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


Glucose Control Algorithms

• 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 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

http://care.diabetesjournals.org/lookup/suppl/doi:10.2337/dc10-1407/-/DC1

http://care.diabetesjournals.org/lookup/suppl/doi:10.2337/dc10-1407/-/DC1

http://www.hospitalmedicine.org/ResourceRoomRedesign/html/12Clinical_Tools/04_Insulin_OrdersIV.cfm



Rabbit 2 Protocols


Rabbit 2 Protocols


Rabbit 2 Protocols


Rabbit 2 Protocols


Rabbit 2 Protocols


I.V. Insulin Infusion Protocol










Documents

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