A multidisciplinary approach to maintaining optimal glycometabolism in cardiac surgery patients has led to an impressive reduction in deep sternal wound infection rates at one New England hospital.
Lead investigator Dr. Robert Kramer of the Maine Medical Center in Portland told Reuters Health, "The team that participated in our tight glycemic control project demonstrated the value of having front-line workers drive the program."
He added, "The front-line workers – nurses — learned about the evidence supporting the use of tight glycemic control in the setting of cardiac surgery. They participated in the creation of a tool, in this case a color-coded algorithm, and then executed the plan reliably and safely."
Initially, after reviewing data on more than 3000 patients who underwent cardiac surgery between 2004 and 2006, Dr. Kramer and his colleagues developed a protocol for maintaining perioperative blood glucose levels between 80 and 150 mg/dL.
In their report in the May issue of the Archives of Surgery, the authors explain that the nurses found the text-based system cumbersome. In addition, a weak educational program minimized the impact of the intervention. The protocol produced a modest decline in blood glucose levels, but deep sternal wound infection rates remained unchanged.
Subsequently, the cardiac team revised the target blood glucose range to 80 to 120 mg/dL and worked with graduate students, nurses and other staff to develop a color-coded nomogram for bedside use. The team also stressed the dangers of hyperglycemia and the lesser risk of hypoglycemia.
By 18 months after the start of the new program, deep sternal wound infection rates fell from 2.6% to 1.0%, a reduction of more than 60%. Patients with infections now tend to have preoperatively poorly controlled diabetes and comorbidities, according to the researchers.
"The clinical leaders," Dr. Kramer points out, "depended upon feedback from the nurses to continually improve the program."
"Successful execution of a tight glycemic control program by the front-line workers," he concluded, "resulted in favorable outcomes and low hypoglycemia rates. The key is in the execution."
Arch Surg 2008;143:451-456.
Reviewed by Ramaz Mitaishvili, MD
