Management of Morning Hyperglycemia Following Cardiac Surgery

LUMC 2ICU CV-Surgical Team CV Anesthesia Pharmacy Staff Nursing Staff Anesthesia Residents

Identifying the Problem

 Current data demonstrates that poor glycemic control in the critically ill/cardiac surgical population leads to poor clinical outcomes even in patients without diabetes.

Solutions Implemented

 Reviewed scientific literature  Aggressive education of CV surgery team on insulin protocol  PharmD hired for 2ICU with rounding on all patients  Implemented new insulin protocol to all cardiac surgery patients to assure tight glycemic control (80-120mcg/dL)  Appointed a nurse liaison to the hospital Diabetic Committee

Analysis

 The frequency of hyperglycemia on the morning following cardiac surgery have significantly decreased following the transition from IV to subcutaneous protocol and ICU insulin protocol released initially in LUCI and currently in EPIC

Recommendations

for

Study and Action Further

 To study if aggressive management of glucose helps decrease wound infections  To report incidence of hypoglycemia in the cardiac surgery patient population

Results

Morning Glucose Control Following Cardiac Surgery

70 60 50 40 30 UCL = 30.68

20 10

Mean = 13.60

Month (number of results)

These data are confidential and to be used for quality improvement purposes only.

Numerator:

Number of cardiac surgery patients with a normoglycemic (70mg/dL to 120mg/dL) result on the first glucose drawn on post-operative day 1 between 4AM and 8AM

Denominator:

All cardiac surgery patients with a valid glucose reading (40-400mg/dL), drawn on post-operative day 1 from 4AM to 8AM

Data Source:

Clarity database, FORCE database.

Analysis:

The control chart indicates a statistically significant change (improvement) in morning glycemic control, of cardiac surgery patients on post operative day 1, following the initial protocol transition in April 2004. Confidence limits are based on results prior to initial interventions, from 1/03 through 3/04.

70 60 50 40 30 UCL = 30.68

20 10

Mean = 13.60

Results

Morning Glucose Control Following Cardiac Surgery

UCL = 69.25

Mean = 45.24

LCL = 21.23

Month (number of results)

These data are confidential and to be used for quality improvement purposes only.

Numerator:

Number of cardiac surgery patients with a normoglycemic (70mg/dL to 120mg/dL) result on the first glucose drawn on post-operative day 1 between 4AM and 8AM

Denominator:

All cardiac surgery patients with a valid glucose reading (40-400mg/dL), drawn on post-operative day 1 from 4AM to 8AM

Data Source: Analysis:

Clarity database, FORCE database.

Morning glycemic control of cardiac surgery patients on post operative day 1 improved from 14% to 43% of patients following protocol implementation.

Results

Median Morning Glucose Following Cardiac Surgery

200 UCL = 199.50

180 160

Mean = 163.50

140 120 LCL = 127.50

Month of Glucose Result (number of patients)

These data are confidential and to be used for quality improvement purposes only.

Definition:

Median value of first morning glucose (drawn on post-operative day 1 from 4AM to 8AM) for cardiac surgery patients. Glucose readings below 40mg/dL and above 400mg/dL were excluded.

Data Source:

Clarity database, FORCE database.

Analysis:

The control chart indicates a statistically significant change (improvement) in morning glycemic control, of cardiac surgery patients on post operative day 1, following the initial protocol transition in April 2004. Confidence limits are based on results prior to initial interventions, from 1/03 through 3/04.

Results

Median Morning Glucose Following Cardiac Surgery

200 UCL = 199.50

180 160

Mean = 163.50

140 120 LCL = 127.50

100 UCL = 146.51

Mean = 122.93

LCL = 99.36

Month of Glucose Result (number of patients)

These data are confidential and to be used for quality improvement purposes only.

Definition:

Median value of first morning glucose (drawn on post-operative day 1 from 4AM to 8AM) for cardiac surgery patients. Glucose readings below 40mg/dL and above 400mg/dL were excluded.

Data Source:

Clarity database, FORCE database.

Analysis:

Morning glycemic control of cardiac surgery patients on post operative day 1 improved from a median of 164 mg/dL to 123 mg/dL following protocol implementation. The current median value of 123 mg/dL also appears to have decreased from February to September 2005.