• Implementation of Screening Tool for Diabetic Patients Undergoing Interventional Procedure

      Mensah-Acquaye, Gloria; Michael, Kathleen (2019-05)
      Background: In healthcare today, a significant proportion of diabetic patients suffer from pain due to nerve radiculitis. One known treatment for chronic pain includes the use of steroid injections under fluoroscopic guidance. The use of steroids in diabetic patients comes with an increased risk of prolonged hyperglycemia after the procedure. Diabetic patients undergoing procedures with the use of steroids need to be properly screened to reduce their risk of prolonged hyperglycemia after the procedure. Local Problem: A large outpatient interventional pain department within a large health organization experienced an increased number of diabetic patients for steroid injections. Lacking a standardized treatment protocol, all diabetic patients received treatment in the department based on provider preference causing variations in practice. Due to this reason, the department recognize the need for a screening guideline for all diabetic patients undergoing procedure with the use of steroids. The purpose of this quality improvement project was to implement a standardized treatment protocol that included the screening of all diabetic patients prior to undergoing any interventional procedure with the use of steroids. Interventions: During the fall of 2018, a quality improvement project implemented a guidelinebased screening tool. The screening tool was used to screen all diagnosed diabetic patients to ensure they had a recent glycosylated hemoglobin (A1C) level of 9.0 or less within 90 days prior to the procedure and a random blood glucose of 250mg/dL or less on the day of the procedure. The incision criteria for screening included any patient scheduled for a procedure with an existing diagnosis of diabetes. After screening all diabetic, any patient with an A1C greater than 9.0 were reschedule to have their procedure after their blood sugar and A1C meet the guideline standard. They are also referred to the organization’s diabetes management program. An educational program was developed to train provider staff on the use of the screening tool. The screening tool questions were developed and incorporated in the electronic medical record to facilitate the practice change and maintain sustainability. A total of 10 providers in two interventional pain clinics (A and B locations) received education on the screening tool prior to implementation. During the eight-week project implementation timeline, the medical records of all scheduled diabetic patients for the interventional clinics were audited to ensure that they received screening with the tool prior to their steroid injection procedure. Results: Location A had a total of 55 patients who met the project inclusion criteria over the 8week period. Staff compliance with using the screening tool was 96% over the 8-week period. Location B had a total of 43 diabetic patients who met the project inclusion criteria. Staff compliance with using the screening tool prior to patient procedure was 88% over the 8-week period. Conclusions: The diabetic patient screening tool is beneficial for patients and providers. Decreasing prolonged hyperglycemic episodes in diabetic patients after the use of steroids will improve overall patient outcome for diabetic patients who undergo interventional procedure.
    • Perioperative Glucose Management in Orthopedic Surgery

      Madden, Ann Rose; Amos, Veronica Y. (2019-05)
      Background: There is a definitive correlation between perioperative hyperglycemia and negative outcomes in orthopedic surgeries. Vigilant treatment of hyperglycemia (>180 mg/dL) will prevent negative outcomes such as joint failure, infection and pseudarthrosis. Local Problem: A Clinical Practice Guideline (CPG) focusing on the management of perioperative hyperglycemia for patients undergoing orthopedic surgery was created for a community hospital in Southern Maryland. Interventions: Data was collected using the following instruments: Practitioner Feedback Questionnaire (PFQ) and the Appraisal of Guidelines Research and Evaluation II Tool (AGREE II). The acceptance and usability of the clinical practice guideline (CPG) was evaluated through these instruments. Results: The dissemination and collection of the practitioner feedback survey resulted in a 100% response (N=16). The literature search was complete and relevant and the recommendations of the CPG were clear and suitable for the intended patient population. 90% of the clinician’s scores suggested they would feel comfortable utilizing the care model suggested in the CPG. Clinical expertise and demographic variables influenced the responses in the PFQ and Agree II tool. Conclusions: Overall the data collected demonstrated widespread acceptance and approval of this clinical practice guideline.
    • Perioperative Glucose Management to Reduce Surgical Site Infections: Clinical Practice Guideline

      Joseph, Sheilla S.; Gonzalez, Michelle LR; Amos, Veronica Y. (2019-05)
      Background: The association of hyperglycemia during and after surgery has been shown to increase the risk of Surgical Site Infections in multiple surgical specialties. Surgical site infections are a complication that has an annual financial impact of over $3 billion dollars nationally. Patients with poorly controlled glycemic levels are at higher risk for surgical site infections and are commonly predisposed to post-op soft tissue and bone healing complications. Local Problem: A large tertiary medical facility in Maryland requested an updated evidencebased guideline to manage perioperative hyperglycemia to reduce surgical site infections in their adult patient population undergoing elective orthopedic surgeries. A review of the literature revealed current standard of practice recommendations of maintaining glycemic values </= 180 mg/dL demonstrated a stronger link to reducing rates of surgical site infections and other post-op complications. The purpose of this Doctorate of Nursing Practice project was to develop a clinical practice guideline that provided best practice strategies for the management of postoperative hyperglycemia in adult patients undergoing elective orthopedic surgery. Intervention: A clinical practice guideline was developed for this quality improvement project. The project included three Student Nurse Anesthetists as project leaders, and three stakeholders. Stakeholders reviewed and graded the guideline draft using the Appraisal of Guidelines for Research & Evaluation Tool. This tool is an open source appraisal instrument used worldwide to evaluate structure, content and the quality of guidelines. Revisions made to the guideline were based on stakeholder recommendations and the appraisal tool results. Implementation of the project was in the form of a brief formal PowerPoint presentation to the anesthesia department and providers were asked to rate the guideline using the Provider Feedback Questionnaire. The data collected from this questionnaire and the appraisal tool were examined using simple descriptive and correlative statistics. Results were acquired to make final modifications to the guidelines. Results: The overall response to the guideline was favorable. The average percentage scores of the guideline appraisal tool were calculated by domain and showed an overall guideline assessment score of 87%. A total of 23 provider feedback questionnaires were collected; and the most common response was a 3 (Strongly Agree), appearing on 18 out of the 23 survey responses. The overall percentage of respondents’ agreement for the guideline was 79% with a standard deviation of 10%. In total, these results are very promising for continuing to explore the implementation of the guidelines. Conclusion: Perioperative glycemic control of </= 180mg/dL has been demonstrated to reduce the incidence of surgical site infections in adult patients undergoing orthopedic surgery. This clinical practice guideline was developed and implemented specifically for this institution. The guideline found strong support among the end users/stakeholders and both doctors and nurses strongly approved of the guidelines. The results of the provider feedback questionnaire indicated effective and internal reliability in which implementing the Guidelines would result in decreasing the rate of perioperative hyperglycemia and the rates of surgical site infections. Further evaluation of patient outcomes after implementation of the guidelines is recommended to measure continued guideline efficacy.
    • Perioperative Glucose Management to Reduce Surgical Site Infections: Clinical Practice Guideline

      Santiago, Frances; Gonzalez, Michelle L. R.; Amos, Veronica Y. (2019-05)
      Background: The association of hyperglycemia during and after surgery has been shown to increase the risk of surgical site infections in multiple surgical specialties. Patients with poorly controlled blood glucose levels are at higher risk for surgical site infections and are commonly predisposed to post-op soft tissue and bone healing complications. Maintaining blood glucose values < 140 mg/dL demonstrated a stronger link to reducing rates of surgical site infections and other postoperative outcomes. Local Problem: The purpose of this project is to develop a clinical practice guideline that provides clear directions and constitutes best practice strategies for the management of hyperglycemia throughout the perioperative period of adult patients undergoing surgery at a tertiary medical facility in Maryland. This facility identified a rise in the incidence of post-op hyperglycemia with blood glucose levels ≥ 180 mg/dl and an increase in post-op surgical site infections in their patient population. Interventions: This project took place in three phases over a 14-week period. The first phase included recruitment of an expert panel consisting of an anesthesiologist and Certified Registered Nurse Anesthetist. After project buy-in, a draft of the guideline was presented to the panel. They reviewed and graded the guideline draft using the AGREE II Tool. Revisions were made based on the panel’s recommendations and AGREE II results. In phase two, a final meeting was held with the chief anesthesiologist for feedback and approval of the final presentation to the anesthesia providers. In phase three, a brief formal presentation was given to the anesthesia department. Anesthesia providers were asked to rate the guideline using the Provider Feedback Questionnaire. The data collected from the Provider Feedback Questionnaire surveys were analyzed and results were obtained to make final changes to the guideline. Results: The guideline provided clear instructions, produced positive patient outcomes, and was deemed favorable by the anesthesia department. Some providers felt the financial implications would hinder implementation, while others were unsure of changing their practice due to the rigid guidelines. Conclusions: This guideline was successfully developed and implemented at the requesting institution with the support of key stakeholders. Monitoring and managing hyperglycemic blood glucose levels in the perioperative period can decrease the incidence of postoperative surgical site infections.
    • Perioperative Glycemic Control to Reduce Surgical Site Infections: Clinical Practice Guideline

      Labang, Tara M.; Gonzalez, Michelle L.R.; Amos, Veronica Y. (2019-05)
      Background: Surgical site infections are a common postoperative complication that has been identified to be related to perioperative hyperglycemia. During times of stress, including surgical stress and anesthesia, the body responds by increasing levels of glucose to meet metabolic demands and reduces the production of insulin, leading to hyperglycemia. Intraoperative blood glucose monitoring and treatment has been demonstrated to reduce the incidence of hyperglycemic events and reducing the incidence of postoperative complications. Local Problem: A tertiary medical center in Maryland requested an updated, evidence-based clinical practice guideline for perioperative glucose management. This clinical practice guideline will provide an evidence-based approach for the following: intraoperative glycemic control, blood glucose monitoring frequency, intraoperative insulin pump management and insulin administration. Interventions: The purpose of this Doctorate of Nursing Practice project was to develop a clinical practice guideline for perioperative glycemic control to reduce surgical site infections in orthopedic surgical patients. This clinical practice guideline was designed for quality improvement purposes and conducted through a combined effort of three student registered nurse anesthetists as project leaders. Feedback and recommendations of the clinical practice guideline were received by key stakeholders through the utilization of the AGREE II tool. Implementation of the project was done via a PowerPoint presentation of the final clinical practice guideline to the end-users, the anesthesia staff, at the facility during the anesthesia staff meeting. End-users provided feedback of the clinical practice guideline via a Practitioner Feedback Questionnaire and demographic questionnaire to evaluate the clinical practice guideline. Data collected using The Agree II tool and Practitioner Feedback Questionnaire were analyzed using simple descriptive and correlative statistics. Results: The mean overall guideline assessment score of the AGREE II tool results was 87%. Both stakeholders rated the overall quality of the guideline with high quality ratings and indicated “yes” to recommending this guideline for use. Descriptive statistics were calculated for the sample of anesthesia providers (n = 23) who completed a Practitioner Feedback Questionnaire. Demographic data revealed that of the 23 respondents, six were anesthesiologists (26%), 16 were certified registered nurse anesthetists (70%), and one student registered nurse anesthetist (4%). Analysis of the Practitioner Feedback Questionnaire results support this clinical practice guideline. The average total percentage of agreement was 80.5% (SD=0.12); indicating the acceptability and usability of this clinical practice guideline by the anesthesia providers at this institution. Conclusions: Perioperative glycemic control has been shown to decrease surgical site infections rates. Recent evidence-based research demonstrates that a target glucose level of <180 mg/dL is effective in reducing surgical site infections, as well as reducing the risk of intraoperative hypoglycemic events. This clinical practice guideline was developed and successfully implemented specifically for this institution as requested to meet the needs of this anesthesia department. Sustainability and spread of the clinical practice guideline will be dependent on the institution.