2231-PUB: Perioperative Glucose Control Protocol: Hip and Knee Arthroplasty

Diabetes and stress hyperglycemia is associated with surgical site infections and other complications. Glucose control may be a modifiable risk factor. Our hospital and healthcare system did not have a standardized protocol for perioperative glucose management. There was variability in pre-surgery diabetes medication adjustments, no proactive glucose monitoring, no glucose control metrics and variable approaches to peri-operative glucose management. We, therefore, initiated a pilot quality improvement project. The population selected were total hip and knee replacement patients as diabetes (∼25%) is a common co-morbidity and there was a signal that diabetes (40% of cases) was associated with deep surgical site infections. The project was an opportunity to implement a population health approach to peri-operative and inpatient glucose management; decrease practice variability and foster a multi-disciplinary team approach. We standardized the recommended adjustments of diabetes medications prior to surgery (e.g., basal insulin decreased 20% the day before surgery); established a uniform A1c threshold of 8% (changed to 7.5%) to postpone surgery and started routine glucose monitoring on the day of surgery in all joint surgery cases. We implemented a standardized correction insulin protocol to be used by anesthesiology and encouraged the use of basal-meal-correction insulin, rather than sliding scale insulin, after surgery, in suitable patients by the hospitalists. The quality project showed a dramatic decrease in hypoglycemia on the day of surgery (∼95% decrease), significantly increased A1c monitoring (3 fold), detected unrecognized diabetes (13%), prediabetes (37%) and stress hyperglycemia and increased the use of correction insulin. Although suggestive, the small sample size and short intervention duration (6 months) were insufficient to detect a significant drop in infection rates. This project is in sustain phase and expanding to other high risk surgeries and can be a model for the entire system.