Prevention of SSI- Applying the Glucose Control Component Sharing the HHS Experience Dr. Richard McLean, MD, FRCP(C) Emily Christoffersen RN, BScN Rhonda Smith RN, BScN, MEd
Jan 13, 2016
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