• 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.