Original Article

CME Article: Reducing Infection Rates with Enhanced Preoperative Diabetes Mellitus Diagnosis and Optimization Processes

Authors: Sher-Lu Pai, MD, Daniela A. Haehn, MD, Nancy E. Pitruzzello, DNP, APRN, MSN, Sarika N. Rao, DO, Shon E. Meek, MD, PhD, Joan M. Irizarry Alvarado, MD

Abstract

Objectives: Hyperglycemia and increased preoperative hemoglobin A1c (HbA1c) are associated with perioperative morbidity and death. For nonurgent operations, adequate glycemic control before surgery is recommended. Our surgical practice needed a process for preoperative diabetes mellitus (DM) diagnosis and glycemic optimization.

Methods: Our review of the existing preoperative evaluation process found that patients without a DM diagnosis but with random plasma glucose ≥200 mg/dL received no additional screening. Patients with DM routinely receive neither preoperative HbA1c screening nor DM management when HbA1c is ≥8.0%.

Results: A new preoperative evaluation process was designed. HbA1c screening was automatically performed for patients with random plasma glucose ≥200 mg/dL. For patients with a DM diagnosis, an HbA1c test was performed. Specialty consultation was prompted for patients with known DM and HbA1c ≥8.0% and those with no DM diagnosis but HbA1c ≥6.5%. In the first year postimplementation, 9320 patients received a basic metabolic panel; 263 had random plasma glucose ≥200 mg/dL that triggered an HbA1c check. In total, 123 patients (99 with and 24 without a DM diagnosis) were referred to endocrinology; 13 received a new DM diagnosis. Twenty patients had surgery delayed for DM treatment. All of the patients received individualized medication instructions for the perioperative period. Among patients with random plasma glucose ≥200 mg/dL, incidence rates for surgical site infection pre- and postimplementation were 47.8/1000 and 3.8/1000 population.

Conclusions: The implemented process benefited patients scheduled for nonurgent procedures by optimizing glucose control and lowering infection rates through earlier preoperative DM diagnosis, glycemic management, and standardized patient medication instruction.
Posted in: Endocrinology, Diabetes, and Metabolism40

This content is limited to qualifying members.

Existing members, please login first

If you have an existing account please login now to access this article or view purchase options.

Purchase only this article ($25)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1. Centers for Disease Control and Prevention. Diabetes and prediabetes. https://www.cdc.gov/chronicdisease/resources/publications/factsheets/diabetes-prediabetes.htm. Accessed March 18, 2021.
 
2. Akhtar S, Barash PG, Inzucchi SE. Scientific principles and clinical implications of perioperative glucose regulation and control. Anesth Analg 2010;110:478–497.
 
3. Kwon S, Thompson R, Dellinger P, et al. Importance of perioperative glycemic control in general surgery: a report from the Surgical Care and Outcomes Assessment Program. Ann Surg 2013;257:8–14.
 
4. Bock M, Johansson T, Fritsch G, et al. The impact of preoperative testing for blood glucose concentration and haemoglobin A1c on mortality, changes in management and complications in noncardiac elective surgery: a systematic review. Eur J Anaesthesiol 2015;32:152–159.
 
5. Tennyson C, Lee R, Attia R. Is there a role for HbA1c in predicting mortality and morbidity outcomes after coronary artery bypass graft surgery? Interact Cardiovasc Thorac Surg 2013;17:1000–1008.
 
6. Noordzij PG, Boersma E, Schreiner F, et al. Increased preoperative glucose levels are associated with perioperative mortality in patients undergoing noncardiac, nonvascular surgery. Eur J Endocrinol 2007;156:137–142.
 
7. Joshi GP, Chung F, Vann MA, et al. Society for Ambulatory Anesthesia consensus statement on perioperative blood glucose management in diabetic patients undergoing ambulatory surgery. Anesth Analg 2010;111: 1378–1387.
 
8. AskMayoExpert. Preoperative Evaluation (POE) Clinic testing guidelines (adult). Mayo Foundation for Medical Education and Research, 2021. https://askmayoexpert.mayoclinic.org/topic/clinical-answers/gnt-20509741/sec-20509743. Accessed July 14, 2021.
 
9. Bierle DM, Raslau D, Regan DW, et al. Preoperative evaluation before noncardiac surgery. Mayo Clin Proc 2020;95:807–822.
 
10. Irizarry-Alvarado JM, Lundy M, McKinney B, et al. Preoperative evaluation clinic redesign: an initiative to improve access, efficiency, and staff satisfaction. Am J Med Qual 2019;34:348–353.
 
11. American Diabetes Association. Understanding A1C: diagnosis. https://diabetes.org/diabetes/a1c/diagnosis. Accessed March 18, 2021.
 
12. Kristensen SD, Knuuti J, Saraste A, et al. 2014 ESC/ESA guidelines on non-cardiac surgery: cardiovascular assessment and management. The Joint Task Force on Non-cardiac Surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J 2014;35:2383–2431.
 
13. American Diabetes Association. Standards of medical care in diabetes— 2020. Abridged for primary care providers. Clin Diabetes 2020;38:10–38.
 
14. Aniskevich S, Renew JR, Chadha RM, et al. Pharmacology and perioperative considerations for diabetes mellitus medications. Curr Clin Pharmacol 2017; 12:157–163.
 
15. Mayo Foundation for Medical Education and Research. Diabetes Medication Instructions: Tests, Procedures and Surgeries That Require Fasting. 2020. http://mayoweb.mayo.edu/sp-forms/mc6300-mc6399/mc6346.pdf. Accessed March 18, 2021.
 
16. American Diabetes Association. 10. Cardiovascular disease and risk management: Standards of medical care in diabetes-2020. Diabetes Care 2020;43:S111–S134.