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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
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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
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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]
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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
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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
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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?
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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 –2 nd run “naive” team Build process with an eye on sustainability
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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
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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
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