ENDOCRINE PRACTICE Rapid Electronic Article in Press Rapid Electronic Articles in Press are preprinted manuscripts that have been reviewed and accepted for publication, but have yet to be edited, typeset and finalized. This version of the manuscript will be replaced with the final, published version after it has been published in the print edition of the journal. The final, published version may differ from this proof. DOI:10.4158/EP14228.OR © 2014 AACE.
Original Article
EP14228.OR
EARLY IDENTIFICATION OF INDIVIDUALS WITH POORLY CONTROLLED DIABETES UNDERGOING ELECTIVE SURGERY: IMPROVING A1C TESTING IN THE PRE-OPERATIVE PERIOD. Patricia Underwood 1,2, Johanna Seiden 1, Kyle Carbone1, Bindu Chamarthi1, Alexander Turchin1,3, Angela M Bader 4, Rajesh Garg 1 Running Title: Improving A1C Testing From: 1Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115; 2 Center for Nursing Excellence, Department of Nursing, Brigham and Women’s Hospital, Boston Massachusetts 02115; 3 Harvard Clinical Research Institute, Boston, MA 02215 4 Department of Anesthesia, Pain, and Perioperative Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115. Correspondence address: Rajesh Garg, M.D. Division of Endocrinology, Diabetes and Hypertension Brigham and Women's Hospital, Harvard Medical School 221 Longwood Ave, Boston, MA 02115 Email: [email protected]
DOI:10.4158/EP14228.OR © 2014 AACE.
Abstract: Objective: To describe a process improvement strategy that increased the identification of individuals with poorly controlled diabetes (Hemoglobin A1C ≥ 8%) undergoing elective surgery at a major academic medical center and increased their access to specialist care. Methods: An algorithm was developed to ensure A1C measurements were obtained as per the AACE /ADA guidelines. The diabetes management team worked collaboratively with anesthesiologists, surgeons, and pre-operative nurse practitioners to improve glycemic control of patients with an A1C ≥ 8%. Results: Before implementing the program, A1C testing was recorded in 854 out of 2335 (37%) patients with diabetes seen in the pre-operative clinic from January 1, 2011 to December 31, 2012. The program was instituted in February 2013. From February 2013 to February 2014, A1C testing occurred in 1236 out of 1334 (93%) patients with diabetes. Of the 1236 individuals with A1C testing, after excluding those scheduled for same day surgery, 228 patients were considered high risk with A1C ≥8% and 175 of them were available for endocrine pre-operative consultation. The program led to significant improvement in blood glucose levels on the day of surgery. Conclusion: A process improvement strategy to evaluate and treat diabetes in the preoperative period of elective surgery patients was implemented by a multi-disciplinary team (endocrinologists, nurse practitioners, anesthesiologists, and surgeons) and resulted in a substantial improvements in obtaining A1C tests, access to specialist diabetes care and glycemic
DOI:10.4158/EP14228.OR © 2014 AACE.
control on the day of surgery. Impact of improved glycemic control on hospital and surgical outcomes needs further evaluation. Key Words: Preoperative glycemic control, Elective surgery, Process improvement, HbA1c
DOI:10.4158/EP14228.OR © 2014 AACE.
Abbreviations: AACE = American Association of Clinical Endocrinologists: ADA = American Diabetes Association; DMS = diabetes management service; A1C = Hemoglobin A1C; IRB = Institutional Review Board; PGMS = Pre-operative glucose management service.
Introduction Acute hyperglycemia during the peri and post-operative period is associated with poor surgical outcomes in individuals with and without diabetes (1-3). Further, chronic hyperglycemia, as measured by the hemoglobin A1c (A1C) value, is associated with increased hospital length of stay (4), wound infection (5, 6) and acute renal failure (5) in surgical patients. Earlier identification of individuals with hyperglycemia in the surgical setting is warranted to prevent hyperglycemia and subsequent surgical complications. Unfortunately, many academic medical centers report underutilization of inpatient glycemic control measures and low rates of A1C testing at the pre-operative visit (4, 7). A1C testing before surgery in those with known diabetes or elevated fasting or random blood glucose levels can identify patients with poorly controlled diabetes who may need specialist diabetes care. To address this issue we developed a strategy to increase the frequency of A1C testing in all patients with diabetes during their pre-operative evaluation visit. Individuals considered high risk for poor surgical outcomes (A1C ≥8%) (4) were then referred to a newly established pre-operative glucose management service (PGMS) with the goal of decreasing hyperglycemia during the peri and post-operative period. Herein, we report the implementation and outcomes of this process improvement strategy. Methods
DOI:10.4158/EP14228.OR © 2014 AACE.
The project was conducted as a quality improvement project with permission from the Institutional Review Board (IRB). Data collection was conducted prospectively and retrospectively with IRB approval. Identification of the Problem Baseline assessment of A1C testing during pre-operative visits was done through retrospective review of medical records databases. A1C value within 3 months before the date of surgery was sought for all individuals with a diagnosis of diabetes mellitus seen in the preoperative evaluation center at the Brigham and Women’s Hospital from January 1, 2011 to December 31st, 2012. Focus Groups with Surgery and Anesthesia Departments Our multidisciplinary endocrine team (Endocrinologist, Nurse Practitioners, and Program Coordinator) met with leaders from the Departments of Anesthesia and Surgery to evaluate barriers to A1C measurements in patients with diabetes. We uncovered that while our hospital had a policy to evaluate A1C in individuals with diabetes seen in the pre-operative clinic; this was not being done regularly due to lack of support from diabetes team. The pre-operative center is a busy clinic with over 400 patients per week. An average of 13 nurse practitioners evaluate patients on a daily basis, with two anesthesiologists available to supervise the assessments performed each day Feedback from all clinicians indicated that A1C was often not ordered due lack of clinical knowledge and concerns that appropriate follow-up would be difficult to arrange for those with elevated A1C. Development and Description of Preoperative Glucose Management Service (PGMS) DOI:10.4158/EP14228.OR © 2014 AACE.
A team of expert diabetes clinicians was created to provide a response to the needs outlined by the clinicians in the pre-operative center. This team consisted of two attending endocrinologists, a nurse practitioner trained in diabetes management, and an administrator. Each team member was allocated the following specific tasks: Endocrine Attendings: Developed pre-operative diabetes protocol and oversaw the implementation and evaluation of the protocol in collaboration with the anesthesia and surgical chiefs. Endocrine Nurse Practitioners: The Endocrine nurse practitioner worked with the pre-operative nurse practitioners to develop an algorithm that would assist the nurse practitioners with clinical decisions. The endocrine nurse practitioner was responsible for providing in-service educational lectures regarding appropriate diabetes management for surgical patients to nurse practitioners working in the pre-operative center. The Endocrine nurse practitioner also provided the glucose management plan for patients prior to surgery in discussion with endocrine attending physicians.
Administrator: Responsible for data collection, meeting coordination, and coordinating patient communication with clinicians on the team. Further, the administrator followed A1C testing daily to insure appropriate tests were obtained and networked with all nurse practitioners to ensure testing was done appropriately. Development of A1C Testing algorithm An algorithm was developed for the preoperative clinic providers to facilitate decision making for A1C testing (Figure 1). The algorithm outlines that A1C test should be ordered if 1) patient DOI:10.4158/EP14228.OR © 2014 AACE.
has prior diagnosis of diabetes and no A1C value is available within the last 3 months or 2) patient has no diabetes mellitus but has a recorded random blood glucose ≥200mg/dl (so that those with undiagnosed diabetes were not missed). For patients not meeting these criteria, no A1C is required during the preoperative evaluation. Communication with PGMS Both an email system and pager system was set up to notify PGMS of patients scheduled for elective surgery and meeting high risk criteria (A1C ≥8%). The administrator oversaw all calls and emails and forwarded to the appropriate clinician for follow up within 24 hours during the work week and 48 hrs during the weekend. Development of Pre-operative Glycemic Control Plan: Patients identified with A1C ≥ 8% were contacted via telephone within 24-48 hrs of their preoperative appointment. Individuals expected to be discharged from the hospital same day after surgery were not included in the program since the purpose of the program was to both improve blood sugar on the day of surgery and during hospitalization by initiating consult with the inpatient diabetes management service. Individuals with A1C ≥ 8% not enrolled, were notified of result and asked to follow up with their primary care clinician. A medication and lifestyle intervention plan was developed based on the patient’s current medication regime, blood glucose levels, and time available before surgery. Surgery was not delayed for the purpose of improving glycemic control. Interventions to improve glycemic control varied depending on the individual’s clinical needs.
DOI:10.4158/EP14228.OR © 2014 AACE.
Once high risk patients were identified using the pre-operative A1C protocol, the established inpatient diabetes management service (DMS) was notified of the patient’s surgery date. A DMS clinician provided diabetes consultation within 12 hours of the end of surgery and daily glycemic management for the duration of the patient’s hospital stay using standard in-patient diabetes management guidelines (8). Further, discharge recommendations were made to improve long term glycemic control. Evaluation of Clinician Satisfaction A survey was developed and administered to the anesthesia nurse practitioners to evaluate whether they perceived that the algorithm and endocrine led support improved or hindered work flow. Evaluation was done 6 months after program implementation. Scores were based on a 1-5 Likert scale. Data collection Frequency of A1C testing, high A1C values and patient referral to PGMS was evaluated prospectively from February 1, 2013 to Feb 28, 2014. Blood glucose level on the day of surgery before induction of anesthesia was obtained. Analyses Population characteristics are presented as frequencies or mean ± standard deviation. Two group comparisons were analyzed using a Pearson’s chi-square test for categorical variables. For group comparisons of continuous variables unpaired t test or Mann-Whitney rank-sum test was used. P value 200
50 40
%
Original Article
EP14228.OR
EARLY IDENTIFICATION OF INDIVIDUALS WITH POORLY CONTROLLED DIABETES UNDERGOING ELECTIVE SURGERY: IMPROVING A1C TESTING IN THE PRE-OPERATIVE PERIOD. Patricia Underwood 1,2, Johanna Seiden 1, Kyle Carbone1, Bindu Chamarthi1, Alexander Turchin1,3, Angela M Bader 4, Rajesh Garg 1 Running Title: Improving A1C Testing From: 1Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115; 2 Center for Nursing Excellence, Department of Nursing, Brigham and Women’s Hospital, Boston Massachusetts 02115; 3 Harvard Clinical Research Institute, Boston, MA 02215 4 Department of Anesthesia, Pain, and Perioperative Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115. Correspondence address: Rajesh Garg, M.D. Division of Endocrinology, Diabetes and Hypertension Brigham and Women's Hospital, Harvard Medical School 221 Longwood Ave, Boston, MA 02115 Email: [email protected]
DOI:10.4158/EP14228.OR © 2014 AACE.
Abstract: Objective: To describe a process improvement strategy that increased the identification of individuals with poorly controlled diabetes (Hemoglobin A1C ≥ 8%) undergoing elective surgery at a major academic medical center and increased their access to specialist care. Methods: An algorithm was developed to ensure A1C measurements were obtained as per the AACE /ADA guidelines. The diabetes management team worked collaboratively with anesthesiologists, surgeons, and pre-operative nurse practitioners to improve glycemic control of patients with an A1C ≥ 8%. Results: Before implementing the program, A1C testing was recorded in 854 out of 2335 (37%) patients with diabetes seen in the pre-operative clinic from January 1, 2011 to December 31, 2012. The program was instituted in February 2013. From February 2013 to February 2014, A1C testing occurred in 1236 out of 1334 (93%) patients with diabetes. Of the 1236 individuals with A1C testing, after excluding those scheduled for same day surgery, 228 patients were considered high risk with A1C ≥8% and 175 of them were available for endocrine pre-operative consultation. The program led to significant improvement in blood glucose levels on the day of surgery. Conclusion: A process improvement strategy to evaluate and treat diabetes in the preoperative period of elective surgery patients was implemented by a multi-disciplinary team (endocrinologists, nurse practitioners, anesthesiologists, and surgeons) and resulted in a substantial improvements in obtaining A1C tests, access to specialist diabetes care and glycemic
DOI:10.4158/EP14228.OR © 2014 AACE.
control on the day of surgery. Impact of improved glycemic control on hospital and surgical outcomes needs further evaluation. Key Words: Preoperative glycemic control, Elective surgery, Process improvement, HbA1c
DOI:10.4158/EP14228.OR © 2014 AACE.
Abbreviations: AACE = American Association of Clinical Endocrinologists: ADA = American Diabetes Association; DMS = diabetes management service; A1C = Hemoglobin A1C; IRB = Institutional Review Board; PGMS = Pre-operative glucose management service.
Introduction Acute hyperglycemia during the peri and post-operative period is associated with poor surgical outcomes in individuals with and without diabetes (1-3). Further, chronic hyperglycemia, as measured by the hemoglobin A1c (A1C) value, is associated with increased hospital length of stay (4), wound infection (5, 6) and acute renal failure (5) in surgical patients. Earlier identification of individuals with hyperglycemia in the surgical setting is warranted to prevent hyperglycemia and subsequent surgical complications. Unfortunately, many academic medical centers report underutilization of inpatient glycemic control measures and low rates of A1C testing at the pre-operative visit (4, 7). A1C testing before surgery in those with known diabetes or elevated fasting or random blood glucose levels can identify patients with poorly controlled diabetes who may need specialist diabetes care. To address this issue we developed a strategy to increase the frequency of A1C testing in all patients with diabetes during their pre-operative evaluation visit. Individuals considered high risk for poor surgical outcomes (A1C ≥8%) (4) were then referred to a newly established pre-operative glucose management service (PGMS) with the goal of decreasing hyperglycemia during the peri and post-operative period. Herein, we report the implementation and outcomes of this process improvement strategy. Methods
DOI:10.4158/EP14228.OR © 2014 AACE.
The project was conducted as a quality improvement project with permission from the Institutional Review Board (IRB). Data collection was conducted prospectively and retrospectively with IRB approval. Identification of the Problem Baseline assessment of A1C testing during pre-operative visits was done through retrospective review of medical records databases. A1C value within 3 months before the date of surgery was sought for all individuals with a diagnosis of diabetes mellitus seen in the preoperative evaluation center at the Brigham and Women’s Hospital from January 1, 2011 to December 31st, 2012. Focus Groups with Surgery and Anesthesia Departments Our multidisciplinary endocrine team (Endocrinologist, Nurse Practitioners, and Program Coordinator) met with leaders from the Departments of Anesthesia and Surgery to evaluate barriers to A1C measurements in patients with diabetes. We uncovered that while our hospital had a policy to evaluate A1C in individuals with diabetes seen in the pre-operative clinic; this was not being done regularly due to lack of support from diabetes team. The pre-operative center is a busy clinic with over 400 patients per week. An average of 13 nurse practitioners evaluate patients on a daily basis, with two anesthesiologists available to supervise the assessments performed each day Feedback from all clinicians indicated that A1C was often not ordered due lack of clinical knowledge and concerns that appropriate follow-up would be difficult to arrange for those with elevated A1C. Development and Description of Preoperative Glucose Management Service (PGMS) DOI:10.4158/EP14228.OR © 2014 AACE.
A team of expert diabetes clinicians was created to provide a response to the needs outlined by the clinicians in the pre-operative center. This team consisted of two attending endocrinologists, a nurse practitioner trained in diabetes management, and an administrator. Each team member was allocated the following specific tasks: Endocrine Attendings: Developed pre-operative diabetes protocol and oversaw the implementation and evaluation of the protocol in collaboration with the anesthesia and surgical chiefs. Endocrine Nurse Practitioners: The Endocrine nurse practitioner worked with the pre-operative nurse practitioners to develop an algorithm that would assist the nurse practitioners with clinical decisions. The endocrine nurse practitioner was responsible for providing in-service educational lectures regarding appropriate diabetes management for surgical patients to nurse practitioners working in the pre-operative center. The Endocrine nurse practitioner also provided the glucose management plan for patients prior to surgery in discussion with endocrine attending physicians.
Administrator: Responsible for data collection, meeting coordination, and coordinating patient communication with clinicians on the team. Further, the administrator followed A1C testing daily to insure appropriate tests were obtained and networked with all nurse practitioners to ensure testing was done appropriately. Development of A1C Testing algorithm An algorithm was developed for the preoperative clinic providers to facilitate decision making for A1C testing (Figure 1). The algorithm outlines that A1C test should be ordered if 1) patient DOI:10.4158/EP14228.OR © 2014 AACE.
has prior diagnosis of diabetes and no A1C value is available within the last 3 months or 2) patient has no diabetes mellitus but has a recorded random blood glucose ≥200mg/dl (so that those with undiagnosed diabetes were not missed). For patients not meeting these criteria, no A1C is required during the preoperative evaluation. Communication with PGMS Both an email system and pager system was set up to notify PGMS of patients scheduled for elective surgery and meeting high risk criteria (A1C ≥8%). The administrator oversaw all calls and emails and forwarded to the appropriate clinician for follow up within 24 hours during the work week and 48 hrs during the weekend. Development of Pre-operative Glycemic Control Plan: Patients identified with A1C ≥ 8% were contacted via telephone within 24-48 hrs of their preoperative appointment. Individuals expected to be discharged from the hospital same day after surgery were not included in the program since the purpose of the program was to both improve blood sugar on the day of surgery and during hospitalization by initiating consult with the inpatient diabetes management service. Individuals with A1C ≥ 8% not enrolled, were notified of result and asked to follow up with their primary care clinician. A medication and lifestyle intervention plan was developed based on the patient’s current medication regime, blood glucose levels, and time available before surgery. Surgery was not delayed for the purpose of improving glycemic control. Interventions to improve glycemic control varied depending on the individual’s clinical needs.
DOI:10.4158/EP14228.OR © 2014 AACE.
Once high risk patients were identified using the pre-operative A1C protocol, the established inpatient diabetes management service (DMS) was notified of the patient’s surgery date. A DMS clinician provided diabetes consultation within 12 hours of the end of surgery and daily glycemic management for the duration of the patient’s hospital stay using standard in-patient diabetes management guidelines (8). Further, discharge recommendations were made to improve long term glycemic control. Evaluation of Clinician Satisfaction A survey was developed and administered to the anesthesia nurse practitioners to evaluate whether they perceived that the algorithm and endocrine led support improved or hindered work flow. Evaluation was done 6 months after program implementation. Scores were based on a 1-5 Likert scale. Data collection Frequency of A1C testing, high A1C values and patient referral to PGMS was evaluated prospectively from February 1, 2013 to Feb 28, 2014. Blood glucose level on the day of surgery before induction of anesthesia was obtained. Analyses Population characteristics are presented as frequencies or mean ± standard deviation. Two group comparisons were analyzed using a Pearson’s chi-square test for categorical variables. For group comparisons of continuous variables unpaired t test or Mann-Whitney rank-sum test was used. P value 200
50 40
%
