Perioperative Glycemic Control to Reduce Surgical Site Infections: Clinical Practice Guideline

Abstract

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.