title: Early Identification of Individuals with Poorly Controlled Diabetes Undergoing Elective Surgery: Improving A1C Testing in the Preoperative Period.
abstract: OBJECTIVE
  To describe a process improvement strategy that increased the identification of individuals with poorly controlled diabetes (glycated 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 American Association of Clinical Endocrinologists/American Diabetes Association (AACE/ADA) guidelines. The diabetes management team worked collaboratively with anesthesiologists, surgeons, and preoperative nurse practitioners to improve the glycemic control of patients with an A1C ≥8%.
  
  
  RESULTS
  Before implementing the program, A1C testing was recorded in 854 out of 2,335 (37%) patients with diabetes seen in the preoperative 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 1,236 out of 1,334 (93%) patients with diabetes. After excluding those scheduled for same day surgery, 228 patients were considered high risk with A1C ≥8%, and 175 were available for endocrine preoperative consultation. The program led to significant blood glucose level improvements on the day of surgery.
  
  
  CONCLUSIONS
  A process improvement strategy to evaluate and treat diabetes in the preoperative period of elective surgery patients was implemented by a multidisciplinary team (endocrinologists, nurse practitioners, anesthesiologists, and surgeons) and resulted in a substantial improvements in obtaining A1C tests, access to specialist diabetes care, and glycemic control on the day of surgery. The impact of improved glycemic control on hospital and surgical outcomes needs further evaluation.
authors.affiliation: Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts Center for Nursing Excellence, Department of Nursing, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Patricia
authors.initials: P
authors.lastname: Underwood
authors.affiliation: Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Johanna
authors.initials: J
authors.lastname: Seiden
authors.affiliation: Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Kyle
authors.initials: K
authors.lastname: Carbone
authors.affiliation: Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Bindu
authors.initials: B
authors.lastname: Chamarthi
authors.affiliation: Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts Harvard Clinical Research Institute, Boston, Massachusetts.
authors.forename: Alexander
authors.initials: A
authors.lastname: Turchin
authors.affiliation: Department of Anesthesia, Pain, and Perioperative Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Angela M
authors.initials: AM
authors.lastname: Bader
authors.affiliation: Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Rajesh
authors.initials: R
authors.lastname: Garg
mesh_terms: D001786:Blood Glucose / Q000032:analysis; D003920:Diabetes Mellitus / Q000097:blood / Q000175:diagnosis*; D017558:Elective Surgical Procedures; D006442:Glycated Hemoglobin / Q000032:analysis*; D006801:Humans
chemical_list: D001786:Blood Glucose; D006442:Glycated Hemoglobin; C517652:hemoglobin A1c protein, human