1. 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

2. 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

3. 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]

4. 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

5. 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

6. 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?

7. 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

8. 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

9. 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