Clinical nurse specialists lead teams to impact glycemic control after cardiac surgery

The purpose of this evidence-based practice improvement project was to improve patients' blood glucose control after cardiac surgery, specifically aiming to keep blood glucose levels less than 200 mg/dL.

Glycemic control is essential for wound healing and infection prevention. Multiple factors including the use of corticosteroids and the stress of critical illness put cardiac surgery patients at greater risk for elevated blood glucose levels postoperatively. A Surgical Care Improvement Project measure related to infection prevention calls for the morning blood glucose level (closest to 6:00 AM) to be less than 200 mg/dL on postoperative days 0 to 2. Patients on our cardiothoracic surgery unit were experiencing blood glucose levels greater than benchmark goals.

A practice improvement effort was designed to decrease the number of blood glucose results greater than 200 mg/dL after cardiac surgery. The clinical nurse specialists for diabetes and cardiac surgery worked with nursing staff and the interdisciplinary team to implement a 4-pronged approach to improve efficiency in care processes: (1) increase frequency of glucose monitoring, (2) improve accessibility of insulin orders, (3) develop delegation protocol to facilitate nurse-initiated insulin infusion, and (4) implement revised insulin infusion protocol.

Hyperglycemia was identified more quickly, and a nurse-initiated protocol prompted more timely use of revised insulin infusion orders and involvement of the diabetes specialty team. Clinically significant improvement in postoperative glycemic control was achieved.

Empowering nurses to initiate hyperglycemia treatment and consultation by diabetes specialists may greatly improve efficiency in care processes and clinical outcomes for cardiac surgery patients.

Clinical nurse specialists are well positioned to plan and implement interventions that facilitate an evidence-based approach to glycemic management after cardiac surgery.