Proven Outcomes in Diabetic Transitions of Care for Post-operative Cardiac Surgery Patients using Pharmacists as Providers
Jan Chow, Pharm.D., BCPS, Kimberly Russell, Pharm.D., BCPS, Jennifer Tryon, Pharm.D., M.S., Michael Barsotti, M.D., Juli Adelman, R.D., CDE
PeaceHealth Southwest Medical Center, Vancouver, Washington
The prevention of post-operative hyperglycemia in cardiac surgery patients has been demonstrated to improve surgical outcomes and reduce sternal wound infections.1 The Centers for Medicare and Medicaid Services adopted the Surgical Care Improvement Project (SCIP) measure of maintaining post-operative day 1 (POD1) and day 2 (POD2) 0600 blood glucose <200 mg/dL (SCIP Inf-4).2 The purpose of this program was to demonstrate the impact of an interdisciplinary glycemic control team on the following outcomes: a) establishment of the role of the pharmacist as an essential leader , b) sustainable achievement of national quality measures (SCIP), c) standardized and evidence-based approach for transitioning patients from insulin infusions to subcutaneous insulin, and d) improvement in transition of care from the hospital to the community by optimizing treatment plans at time of discharge.
An interdisciplinary task force was established in October 2007 to develop a patient-centered glycemic control program for all post-operative cardiac surgery patients. Under supervision of an endocrinologist, a pre-printed order consisting of an insulin infusion and hypoglycemia treatment algorithm, and guidelines for transitioning from intravenous (i.v.) insulin to subcutaneous insulin were developed. Using the protocol, the pharmacist formulated patient-specific treatment plans that included appropriate timing for transitioning to subcutaneous insulin. In conjunction with the cardiac surgeon, the pharmacist and certified diabetes educator initiated and modified diabetes medications and facilitated appropriate discharge planning to ensure continuity of care. Blood glucose data and demographic information were maintained and routinely reviewed to evaluate program outcomes and identify areas of improvement.
Between 2008 and 2011, 912 patients who underwent cardiac surgery were managed by the glycemic control team. Overall compliance with SCIP Inf-4 ranged from 95.2% to 97.6% compared to 93.5% in 2007. In comparison, the current national and state average compliances were 95% and 94% respectively.3 The incidence of hypoglycemia was found to be minimal, with 0.1% of all blood glucose measurements less than 40 mg/dL and 2% less than 70 mg/dL. Of the 595 non-diabetic patients, 62% were transitioned to subcutaneous insulin on POD1 and 23% on POD2. Of the 317 patients with a pre-existing diagnosis of diabetes, 31% were transitioned to subcutaneous insulin on POD1 and 44% on POD2. Of the 100 diabetic patients with HbA1C ≥8%, 90% were maintained on i.v. insulin through POD2 or longer. Interventions to improve overall glycemic control after discharge became a major component of the program. Of the 205 discharge interventions, 112 patients (54.6%) received diabetic medication regimen modifications. Fifty five patients (26.8%) were started on oral diabetic medications. Twelve patients (5.8%) with HbA1c ≥8% were started on insulin which was continued at discharge. Eight patients with diet-controlled diabetes before surgery with HbA1c 7-8% were started on oral medications. Eighteen patients (8.7%) were discharged to skilled nursing facilities with orders to continue the inpatient regimen.
There is little published data regarding implementation of similar programs for managing post-operative cardiac surgery patients. This standardized yet individualized approach provided sustainable achievements in meeting SCIP measures. We demonstrated that a glycemic control program can improve continuity of care from the hospital to the community by optimizing individual treatment plans and facilitating the transition of care.
- Furnary AP, Wu YX. Clinical effects of hyperglycemia in the cardiac surgery population: the Portland diabetic project. Endocr Pract. 2006; 12 Suppl 3:22-6.
- The Joint Commission. Specification Manual for National Hospital Quality Measures Oakbrook Terrace, IL: The Joint Commission, 2009. (accessed 2009 Oct 22).
- American College of Endocrinology and American Association of Clinical Endocrinologists (AACE) diabetes road maps Endocr Pract. 2007; 13:S5-S68.
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