Compliance with surgical care improvement project blood glucose--a marker for euglycemia, but does it put our patients at risk?
To improve outcomes in open heart surgery (OHS) patients, the Surgical Care Improvement Project (SCIP) requires 6 am postoperative day (POD) 1 and 2 blood glucose (BG) to be ≤200mg/dL. This study examined risk factors for SCIP noncompliance when using an insulin infusion protocol (IIP) and evaluated this SCIP metric as a surrogate for glycemic control. The authors divided 99 consecutive OHS patients, all subjected to 1 uniform IIP, into 2 groups: Group 1-SCIP compliant (n=79) and Group 2-SCIP noncompliant (n=20). They determined mean BG for the first 48 postoperative hours, percent of total time with hyperglycemia (% time BG >200mg/dL) for each group, and assessed risk of SCIP noncompliance as relates to multiple risk factors including intensity of IIP application, and switching to subcutaneous (SQ) insulin prior to 6 am on POD 2. Group 1 had lower mean BG than Group 2 and percent of total time with hyperglycemia, P<0.0001. Multivariate analysis showed diabetes, obesity in nondiabetics, and switching to SQ insulin prior to 6 am on POD 2 to be risk factors for SCIP noncompliance. The 6 am BG values on POD 1 or POD 2 each correlated with average postoperative BG, and compliance with the SCIP BG metric was associated with virtually uniform BG ≤200mg/dL. IIP application was not significantly different between groups (P=0.2). Only patients who had been switched to SQ insulin prior to 6 am POD 2 were noncompliant at 6 am on POD 2. There were hypoglycemic events (BG <70mg/dL) in 15 of 99 patients (15%), 12 of whom (80%) were in Group 1. Noncompliance with this SCIP measure occurred more frequently in patients with diabetes or, if nondiabetic, in those patients with obesity. A trend toward increased insulin assessments in the SCIP noncompliant group suggests that 1 uniform IIP for all patients may not be effective. By not requiring the reporting of hypoglycemia, SCIP may inadvertently be exposing patients to harm.
Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA. iwhitman@gmail.com
Isaac R
IR
Whitman
Maura
M
Murphy
Marta M
MM
Gilson
Amy
A
Campfield
Michel
M
Haddad
Elizabeth
E
Moxey
Glenn J R
GJ
Whitman
D000465:Algorithms; D001786:Blood Glucose; D003920:Diabetes Mellitus / Q000188:drug therapy; D005260:Female; D015309:Glucose Clamp Technique; D006801:Humans; D006943:Hyperglycemia / Q000188:drug therapy; D007328:Insulin / Q000627:therapeutic use; D008297:Male; D015999:Multivariate Analysis; D005791:Patient Care / Q000379:methods*; D019990:Perioperative Care / Q000379:methods*; D011787:Quality of Health Care; D012189:Retrospective Studies; D012306:Risk; D012449:Safety; D013997:Time Factors
D001786:Blood Glucose; D007328:Insulin