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

2. Partnership for Patients 40 – Percent reduction in harm 20 – Percent reduction in readmissions 13 – by 2013 Presented July 10, 2012 at the WSHA Safe Table: Reduction of SSI

3. 10 Targeted Strategies Infection 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 immobility 6.Pressure ulcers High Risk: 7.Adverse drug events 8.Obstetrical adverse events 9.Venous thromboembolism or blood clots (VTE) Continuity of Care: 10. Prevention of readmissions Presented July 10, 2012 at the WSHA Safe Table: Reduction of SSI

5. 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

6. Diabetes, Glucose Control, and SSIs After Median Sternotomy Latham. ICHE 2001; 22: 607-12 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

7. Hyperglycemia and Risk of SSI after Cardiac Operations No increased risk: Elevated HgbA1c Preoperative hyperglycemia Increased risk: Diagnosed diabetes Undiagnosed diabetes Post-op glucose > 200 mg% within 48h Latham. Inf Contr Hosp Epidemiol. 2001;22:607 Dellinger. Inf Contr Hosp Epidemiol. 2001;22:604 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

8. Hyperglycemia and Risk of SSI after Cardiac Operations Hyperglycemia - doubled risk of SSI Hyperglycemic: 48% of diabetics 12% of nondiabetics 30% 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 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

9. Deep Sternal SSI and Glucose Zerr. Ann Thorac Surg 1997; 63:356 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

10. Furnary et al. Ann Thorac Surg 1999:67:352 Glucose Control and Deep Sternal Wound Infections 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

11. Glucose Control and Mortality after CABG in 3554 Diabetics Furnary. J Thorac Cardiovasc Surg 2003;125:1007 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

12. 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% 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

13. 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 > 180O.R.=2.03 gluc increase of 40O.R.=1.9 ASA & emergent Ramos. Ann Surg 2008;248: 585–591 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

14. Mastectomy, Hyperglycemia, and SSI 260 patients, 5 glucose determinations (pre-op, at anesthesia induction, intra-op, in PACU, at 24 hrs) Odds Risk FactorRatioC.I. Age > 503.7(1.5-9.2) Pre-Op ChemoRads2.8(1.4-5.8) Any gluc > 150 mg%2.9(1.2-6.2) Villar-Compte. AJIC 2008; 36:192-8 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

15. Postop Glucose (within 48h) and SSI Ata. Arch Surg 2010: 145: 858-864 Glucose 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

16. 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 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

17. Rabbit 2 Study – Surgery Basal/Bolus vs Sliding Scale Insulin Basal BolusSliding Scalep value Patients104107 Mean Fasting1551670.04 Mean Daily157176.001 Readings < 14053%31%.001 Wound infections311.05 Any complication926.003 Umpierrez. Diabetes Care 2011; 34: 256-61 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

18. 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 on POD 1 or POD 2 SCOAP data courtesy of Sung (Steve) Kwon 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

19. SCOAP Data on Perioperative Glucose Levels and Insulin Use Diabetic pts4098 (35%)  Hyperglycemic2369 (58%) Nondiabetic pts7532 (65%)  Hyperglycemic1014 (13%) 30% of all hyperglycemic patients were not diabetic! SCOAP data courtesy of Sung (Steve) Kwon 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

20. Hyperglycemia vs No Hyperglycemia All Patients All p<0.01 SCOAP data courtesy of Sung (Steve) Kwon 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

21. Hyperglycemia vs No Hyperglycemia Diabetic Patients * p<0.05 ** p<0.01 SCOAP data courtesy of Sung (Steve) Kwon 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

22. Hyperglycemia vs No Hyperglycemia Nondiabetic Patients All p<0.01 SCOAP data courtesy of Sung (Steve) Kwon 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

23. Composite Infection in Hyperglycemic Patients With and Without Use of Insulin SCOAP data courtesy of Sung (Steve) Kwon 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

24. Operative Reintervention in Hyperglycemic Patients With and Without Use of Insulin SCOAP data courtesy of Sung (Steve) Kwon 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

25. Mortality in Hyperglycemic Patients With and Without Use of Insulin SCOAP data courtesy of Sung (Steve) Kwon 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

26. 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 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

27. Glucose Control Algorithms The Rabbit 2 basal bolus protocol is online at http://care.diabetesjournals.org/lookup/suppl/d oi:10.2337/dc10-1407/-/DC1 http://care.diabetesjournals.org/lookup/suppl/d oi: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/ResourceRoom Redesign/html/12Clinical_Tools/04_Insulin_Orde rsIV.cfm http://www.hospitalmedicine.org/ResourceRoom Redesign/html/12Clinical_Tools/04_Insulin_Orde rsIV.cfm 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

28. Rabbit 2 Protocols 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

29. Rabbit 2 Protocols 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

30. Rabbit 2 Protocols 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

31. Rabbit 2 Protocols 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

32. Rabbit 2 Protocols 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

33. I.V. Insulin Infusion Protocol 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

34. I.V. Insulin Infusion Protocol 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

35. I.V. Insulin Infusion Protocol 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

36. I.V. Insulin Infusion Protocol 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

37. I.V. Insulin Infusion Protocol 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