Improving Glycemic Control for Post-Operative Cardiac Surgery Patients: A Nurse Practitioner Led Project. Linda Kerr, DNP, RN, FNP-BC, CDE
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1 Improving Glycemic Control for Post-Operative Cardiac Surgery Patients: A Nurse Practitioner Led Project Linda Kerr, DNP, RN, FNP-BC, CDE
2 Problem Statement Hyperglycemia during the first 48 hours following cardiac surgery has been found to be independently associated in the incidence of Deep Sternal Wound Infection (DSWI) (Furnary et al., 2004). Hyperglycemia in hospitalized patients is an independent predictor of mortality for cardiac surgery patients, with or without diabetes (Lazar et al., 2009). Intensive insulin therapy has been shown to increase the occurrence of hypoglycemia and result in complications and adverse clinical outcomes (Preiser et al., 2009). The complexity of insulin therapy, and strategies surrounding planned staff education opportunities, requires clinical providers that are knowledgeable in glycemic management (Moghissi et al., 2009).
3 Background & Significance Study organization: Long Beach Memorial, CA Cardiac surgery patients: Diabetes: 30-40% A1c 5.7% or higher: 60% Surgical Care Improvement Project (SCIP) (9) Quality measures Value-based purchasing measures SCIP-inf-4 glycemic measure Benchmark 99.6%
4 Background & Significance Autonomous NP led team Standardized glycemic processes RN: Cardiac insulin infusion order set NP: Individualized insulin therapy POD 2 Staff education Day shift RNs Nutrition Carbohydrates: 60 grams/meal Sugar free snacks: not consistent
5 Interventions Gap Analysis Environmental stress CCU Census: 42% increase Patient Acuity More regulatory requirements Cardiac insulin infusion order set Inconsistent adherence to order set Nutrition Reduced carbohydrate meals Sugar free snacks Night shift nurse NP Led Intervention Plan RN education: All shifts New SCIP-inf-4 Insulin orders Nutrition Nutrition orders Standardized NP team Individualized insulin: POD 1 Increase availability Clinician Coach Consultant Educator
6 PICO(t) Question Among adult cardiac surgery patients (P), what is the effect of nurse practitioner (NP) led insulin management and glycemic-related process changes (I), compared to existing standards of glycemic care(c), on post-operative hyperglycemia (O)
7 Clinical Scholarly Project (CSP) Aim 1. To determine the effectiveness of an NP led team in improving glycemic control of cardiac surgery patients Aim 2. To determine if NP team management would inadvertently increase the incidence of hypoglycemia Aim 3. To evaluate the CCU nurse s assessment of the clinical change process
8 Literature Review Furnary, et al., (1999) Cardiac surgery patients 2,467 prospective, consecutive diabetic patients Insulin infusion vs sliding scale insulin (SSI) Results Insulin infusion: Significant reduction Perioperative glucose Major infectious morbidity
9 Literature Review Finfer et al. (2009) NICE-SUGAR ICU patient Large, international, randomized trial, 6104 patients Intensive glucose control vs conventional glucose control Results: Intensive glucose control group Increased mortality Increased deaths from cardiovascular causes Preiser et al. (2009) Glucontrol Study ICU patients Prospective randomized controlled trial, 1,750 (1,101) Intensive glucose control vs Intermediate glucose control Results: Intensive glucose control group Prematurely stopped Increased Hypoglycemia
10 Literature Review Inpatient glycemic control Moghissi et al. (2009) Association of Clinical Endocrinologists (AACE), The American Diabetes Association (ADA) Umpierrez et al. (2012) The Endocrine Society, Clinical Practice Guidelines Cardiac surgery and glycemic control Lazar et al. (2009) Society of Thoracic Surgeons (STS) Health System Pharmacy Cobaugh et al. (2013)
11 Literature Review Meyer & Miers (2005) Cardiac surgery Retrospective, 2-group comparison Cardiovascular surgeons Cardiovascular surgeons teamed with acute care nurse practitioners (ACNPs) Economic outcomes: Length of stay & total cost Results Cardiac surgeons + ACNP team
12 Theoretical Framework Figure 1. Knowledge to Action Theory (Straus, Tetroe, & Graham, 2009) Figure 2. Conceptual framework of acute care nurse practitioner role enactment, boundary work, and perceptions of team effectiveness (Kilpatrick et al., 2013)
13 Methodology Design: Single-center descriptive, comparative analysis of an NP led quality improvement project. Pre-intervention: Retrospective chart review Post-intervention: Real time chart review Inclusion Criteria: 18 years of age or greater Coronary artery bypass graft (CABG) Mitral valve repair/replacement (MVR) Aortic valve repair/replacement (AVR) Transcatheter aortic valve replacement (TAVR) Exclusion Criteria: Three or more vasopressors and 20 or more units per hour insulin infusion on postoperative day one Expired prior to discharge Did not require insulin infusion postoperatively Allergic to Levemir (insulin detemir)
14 Methodology Data Analysis SPSS Descriptive Patient demographics Population characteristics Sample Size 183 patients Statistical Tests The Chi-squared test Categorical variables Independent t-test Continuous variables Significance, p -value less than.05
15 Study Instruments Figure 3. Data collection log, cardiac surgery patients
16 Study Instruments: Nursing Survey
17 Study Instruments Figure 4. Nursing education flyers. Sugar free snacks and RN algorithm for when to contact the NP team for insulin management
18 Study Characteristics Pre Intervention Post Intervention p-value Prior to Intervention P-value a Intervention Period Period N=90 N=93 Age, years mean (SD), [range] 65.4 (12.6), [26-88] 66.0 (11.6), [31-92] P=.706 % Male 68.9% 69.9% P=.883 % Diabetes Diagnosis 41.1% 29.0% P=.087 BMI, mean (SD), [range] 28.1 (5.9) 28.1 (5.8) P=.996 Normal weight (<25) b 31.1% 28.0% Overweight (25-30) 37.8% 40.9% Obese (>30) 31.1% 31.2% Surgery Type: P=.829 CABG 66.7% 62.4% AVR 22.2% 24.7% Other 11.1% 12.9% AIC, mean (SD), [range] 6.3 (1.5), [ ] 6.1 (1.0), [ ] P=.246 AIC in diabetics, mean (SD), [range] 7.3 (1.8), [ ] 7.1 (1.3), [ ] P=.615 AIC in non-diabetics, mean (SD), [range] 5.6 (0.6), [ ] 5.7 (0.4), [ ] P=.613 % SCIP-in-4 Glycemic Measure Met 80.9% 97.6% P<.001 % Hypoglycemia event experienced 48 hours 16.9% 14.3% P=.642 following anesthesia end time c Figure 5. a P-value indicates significance of between group (pre vs. post intervention) differences in distributions examined. Significance based on chi-square test statistic for categorical and independent t-test for continuous variables. b Include five underweight patients. C all hypoglycemia events experienced were in the range of 40-69mg/dl
19 Statistical Results Figure 6. Percentage of patients who met SCIP-inf-4 criteria in the intervention periods. Significance of improvement of SCIP-inf-4 criteria for the post-intervention period was based on Chi-square test statistic.
20 Statistical Results 120.0% 100.0% % Patients who experienced hypoglycemia event 48 hours following anesthesia end time 80.0% 60.0% 40.0% 20.0% 16.9% 14.3% 0.0% N=89 N=84 Prior to Intervention Period Intervention Period Intervention period (p=.642) Figure 7. Percentage of patients who experienced a hypoglycemic event within 48 hours following anesthesia end time. Significance was based on the Chi-square test statistic.
21 Statistical Results Nursing Satisfaction Survey Figure 9. Nursing Satisfaction survey.
22 Discussion/Implications NP team New clinical & nutrition processes Staff education/coaching Increased availability Individualized insulin Doctorate of Nursing Practice (DNP) Essentials Leadership in practice Scientific inquiry Integration of scientific knowledge
23 Limitations/Future Research Limitations Limited generalizability Single-center Quality improvement Nursing satisfaction survey Questions not validated Future Research Multi-center, randomized control trials NP management of critical & non-critical patient populations in the hospital setting Impact of NP autonomy Identify effective glycemic management teams
24 Sustainability NP Led Team DNP Essentials RN Education Insulin Management Nutrition Changes
25 Plan for Dissemination Education Symposiums Sigma Theta Tau: 43 rd Biennial Convention, Poster presentation November, 2015 The Western Institute of Nursing Research (WIN): Poster presentation April, 2016 Publications Critical-Care Nurses Nurse Practitioners Diabetes Care Magnet/Nursing Sigma Theta Tau
26 Acknowledgements Study Team Peggy Kalowes, PhD, RN, CNS, FAHA Kim West, MSN, RN, ACNP-BC Barbara Easterbrook, MSN, RN, ANP Darice Hawkins, MN, CNS, CCRN Long Beach Memorial NP Team Cardiac Surgeons Memorial Nursing Staff Administration Teams
27 References Cobaugh, D. J., Maynard, G., Cooper, L., Keinle, P. C., Vigersky, R., Childers, D.,... Cohen, M. (2013). Enhancing insulin-use safety in hospitals: Practical recommendations from an ASHP foundation expert consensus panel. American Journal of Health-System Pharmacy, 70(16), Finfer, S., Chittock, D. R., Su, S. Y., Blair, D., Foster, D., Dhingra, V.,... Ronco, J. J. (2009, March 26). Intensive versus conventional glucose control in critically ill patients. The New England Journal of Medicine, 360(13), Furnary, A. P., Xing, Y., & Bookin, S. O. (2004). Effect of hyperglycemia and continuous intravenous insulin infusions on outcomes of cardiac surgical procedures: The Portland diabetic project. Endocrine Practice, 10(2), Furnary, A. P., Zerr, K. J., Grunkemeier, G. L., & Starr, A. (1999). Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Annals of Thoracic Surgery, 67(2),
28 References Kilpatrick, K., Lavoie-Tremblay, M., Lamonthe, L., Ritchie, J. A., & Doran, D. (2013). Conceptual framework of acute care nurse practitioner role enactment, boundary work, and perceptions of team effectiveness. Journal of Advanced Nursing, 69(1), Lazar, H. L., McDonnell, M., Chipkin, S. R., Furnary, A. P., Engelman, R. M., Sadhu, A. R.,... Shemin, R. J. (2009). The society of thoracic surgeons practice guideline series: Blood glucose management during adult cardiac surgery. Annals of Thoracic Surgery, 87, doi: 10:1016/j.athoracsur Meyer, S. C., & Miers, L. J. (2005). Cardiovascular surgeon and acute care nurse practitioner: Collaboration on postoperative outcomes. American Association of Critical Care Nurses, 16(2), Moghissi, E. S., Korytkowski, M. T., DiNardo, M., Eihorn, D., Hellman, R., Hirsch, I. B.,... Umpierrez, G. E. (2009). American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Endocrine Practice, 15(4), 1-17.
29 References Preiser, J.-C., Devos, P., Ruiz-Santana, S., Melot, C., Annane, D., Groeneveld, J.,... Chiolero, R. (2009). A prospective randomised multi-centre controlled trial on tight glucose control by intensive insulin therapy in adult intensive care units: The Glucontrol study. Intensive Care Medicine, 35(10), Straus, S. E., Tetroe, J., & Graham, I. (2009). Defining knowledge translation. Canadian Medical Association Journal, 181(3-4), Umpierrez, G. E., Hellman, R., Korytkowski, M. T., Kosiborod, M., Maynard, G. A., Montori, V. M.,... Van den Berghe, G. (2012). Management of hyperglycemia in hospitalized patients in non-critical care settings: An endocrine society clinical practice guideline. Journal of Clinical Endocrinology Metabolism, 97(1),
30 Any Questions?
31 Thank You for Your Time and Interest
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