title: Intense implementation of a strict insulin infusion protocol does not guarantee postoperative glycemic control.
abstract: BACKGROUND
  The Surgical Care Improvement Project (SCIP) has benchmarked 6:00 AM blood sugars on postoperative days (PODs) 1 and 2 at <200 mg/dL as an indicator of overall glycemic control (GC) in postoperative cardiac surgery patients. However, even in demonstration hospitals that publicly report for incentive payments, only 10% are compliant with this benchmark. The objectives of this study were to validate that the SCIP indicator correlates with overall GC, and relate the intensity of implementation of an insulin infusion protocol (IIP) (goal, blood sugar 100 to 140 mg/dL) to effective GC.
  
  
  METHODS
  All postoperative cardiac surgery patients for 12 consecutive months on the IIP were divided into 2 groups: group 1 included patients who were SCIP compliant (n = 98), and group 2 were patients who were not SCIP compliant (n = 10). For each patient, we determined average blood sugar, duration of hyperglycemia (percent of time with blood sugar >200mg/dL), and intensity of implementation of the IIP, defined as (number of blood sugar checks/hours on IIP), with 0.5 = minimum intensity of implementation dictated by the IIP, ie, an insulin adjustment every 2 hours.
  
  
  RESULTS
  The average blood sugar for each of the 110 patients was no different than the SCIP 6:00 AM blood sugar: 146 versus 154 mg/dL, p = 0.18. SCIP noncompliance correlated with more intense implementation of the IIP, 0.72 ± 0.03 versus 0.83 ± 0.06 blood sugar checks/hour.
  
  
  CONCLUSIONS
  The SCIP 6:00 AM blood sugar metric does correlate with average blood sugar on POD 1. Compliance with SCIP 6:00 AM blood sugar measurement is a valid surrogate for GC, though duration of hyperglycemia was still 14% in the compliant group. Use of an IIP does not guarantee GC, despite increased intensity of its application. Even intense use of an IIP may be ineffective when it fails to account for patient risk factors for hyperglycemia.
authors.affiliation: Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA.
authors.forename: Maura A
authors.initials: MA
authors.lastname: Murphy
authors.forename: Isaac
authors.initials: I
authors.lastname: Whitman
authors.forename: Amy
authors.initials: A
authors.lastname: Campfield
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Moxey
authors.forename: Michel
authors.initials: M
authors.lastname: Haddad
authors.forename: Glenn
authors.initials: G
authors.lastname: Whitman
mesh_terms: D001786:Blood Glucose / Q000032:analysis*; D006348:Cardiac Surgical Procedures; D002985:Clinical Protocols; D019983:Guideline Adherence; D006801:Humans; D006943:Hyperglycemia / Q000188:drug therapy*; D007004:Hypoglycemic Agents / Q000008:administration & dosage*; D007262:Infusions, Intravenous; D007328:Insulin / Q000008:administration & dosage*; D011184:Postoperative Period
chemical_list: D001786:Blood Glucose; D007004:Hypoglycemic Agents; D007328:Insulin