An interdepartmental collaboration to improve preoperative glycemic control

The Centers for Disease Control and Prevention estimates that 25.8 million adults in the United States have diabetes, and these patients experience higher rates of morbidity and mortality postoperatively than patients without diabetes. While several professional organizations have recommended tight glycemic control perioperatively, the data regarding preoperative glycemic control is only emerging. The hemoglobin A1c level, which reflects long-term glycemic control, has been shown to correlate with postoperative outcomes including length of stay, infections, and mortality. This relationship has implications for the preoperative surgical management of patients with diabetes.

Implemented in 2009, our interdepartmental initiative was designed to improve glycemic control within 5 to 7 days before surgery with a blood glucose target of 100 of 199 mg/dL the morning of surgery. An endocrinologist and a certified diabetes educator evaluate same-day urgent referrals from the anesthesia preoperative clinic, targeting high-risk patients with an HbA1c value of ≥ 9%, a random blood glucose level of ≥ 300 mg/dL, or a fasting blood glucose level of ≥ 240 mg/dL. Our team then creates an individualized preoperative treatment plan based on the patient's prior insulin regimen and diabetes self-management skills. Verbal and written instructions for insulin self-titration and guidance for insulin dose changes in preparation for a fasting state are included.

: With this interdepartmental collaboration, as part of a larger institutional initiative, we hope to improve short- and long-term outcomes for surgical patients with uncontrolled diabetes, as well as improve costs and utilization of health care resources in our institution. Our glycemic control committee, which follows bimonthly metrics, including 90-day readmission rates for surgical patients, has noted a decline from 7.9% in 2009 to 4.5% in the 2012-2013 fiscal year. Our aggressive preoperative and postoperative blood glucose management has been a significant factor in this improvement.