Surgical universal euglycemic attainment during recovery (SUGAR) initiative: Sweet results through quality improvement (286)

Abstract

<b>Objectives:</b> Perioperative hyperglycemia is associated with adverse postoperative outcomes. Lack of standardization leads to inconsistent detection and management of patients with diabetes during the perioperative period. Our objective was to improve perioperative glycemic control among patients with Type II diabetes mellitus undergoing open gynecologic surgery through a quality improvement initiative. <b>Methods:</b> We assembled a multidisciplinary team and implemented standardized screening guidelines, including obtaining a preoperative hemoglobin A1C in all patients before surgery. Algorithms were developed for patients with diabetes, and those at high risk were referred to Endocrinology to optimize glucose control in the preoperative period. We also standardized the intraoperative and postoperative management by increasing the frequency of intraoperative glucose monitoring and developing weight-based postoperative insulin order sets with basal, prandial, and correctional insulin. Outcomes were compared between a baseline (BL) group (February 2015-August 2017) and a post-implementation (PI) group (February 2018-April 2021). Summary statistics were used to describe the clinical and demographic characteristics. BL and PI groups were compared using the Chi-square test, Fisher's exact test, t-test, or Wilcoxon rank-sum test. A linear mixed effect model was constructed based on hours since initial preop measurement, time period measurement took place, and group (BL vs PI). <b>Results:</b> There were 81 patients in the BL group and 119 in the PI group. The BL and PI groups were similar in age, race, and indication for surgery (benign vs malignant). The PI group had lower median BMI (PI 32.7kg/m2 vs BL 35.3mg/m2; p=0.02), higher median Charlson Comorbidity Index (PI 4 vs BL 3; p=0.004), and surgical time (PI 258 minutes vs BL 197 minutes; p=0.009). The rate of obtaining a hemoglobin A1c prior to surgery increased from BL 14.8% to PI 89.0% (p<0.001). The rate of intraoperative glucose monitoring also increased from BL 50.6% to PI 76.5% (p<0.001). The linear mixed-effects model found PI estimated average glucose values decreased by 8.13mg/dL compared to BL levels (p=0.046). The percentage of postoperative glucose values that were at goal (<180mg/ dL) improved from BL 83% to PI 86% (p=0.008). There were no episodes of hypoglycemia or other safety events associated with the postoperative insulin order sets. <b>Conclusions:</b> The SUGAR initiative successfully increased compliance with preoperative screening for diabetes as well as improved perioperative monitoring and management of hyperglycemia. The impact of this initiative on glycemic control is evident not only by the improvement in average glucose values across all time periods but also by the percentage of glucose values that are at goal. This protocol safely improved perioperative glycemic control among patients with diabetes undergoing open gynecologic surgery.