Partnership for Patients
Reducing Surgical Site Infections:
Glucose Control
Clinical Presentation
July 10, 2012
Washington State Hospital Association
Partnership for Patients
• 40 – Percent reduction in harm
• 20 – Percent reduction in readmissions
• 13 – by 2013
Presented July 10, 2012 at the WSHA Safe Table: Reduction of SSI
10 Targeted Strategies
Infection Reduction:
1. Catheter-associated urinary tract infections (CAUTI)
2. Central line-associated blood stream infections (CLABSI)
3. Surgical site infections (SSI)
4. Ventilator-associated pneumonia (VAP)
Nursing Care:
5. Injuries from falls and immobility
6. Pressure ulcers
High Risk:
7. Adverse drug events
8. Obstetrical adverse events
9. Venous thromboembolism or blood clots (VTE)
Continuity of Care:
10. Prevention of readmissions
Presented July 10, 2012 at the WSHA Safe Table: Reduction of SSI
Presented July 10, 2012 at the WSHA Safe Table: Reduction of SSI
Rationale for a focus on Glucose
to Prevent SSI
Presented by E. Patchen Dellinger, M.D.
Professor and Vice Chairman, Department of Surgery
Chief, Division of General Surgery
WSHA Safe Table: Reduction of SSI July 10, 2012
Diabetes, Glucose Control, and SSIs
After Median Sternotomy
% Infections
20
15
10
5
0
<200
200-249
250-299
>300
Latham. ICHE 2001; 22: 607-12
Presented by E. Patchen Dellinger, M.D.
Professor and Vice Chairman, Department of Surgery
Chief, Division of General Surgery
WSHA Safe Table: Reduction of SSI July 10, 2012
Hyperglycemia and Risk of SSI after
Cardiac Operations
• No increased risk:
Elevated HgbA1c
Preoperative hyperglycemia
• Increased risk:
Diagnosed diabetes
Undiagnosed diabetes
Post-op glucose > 200 mg% within 48h
Latham. Inf Contr Hosp Epidemiol. 2001;22:607
Dellinger. Inf Contr Hosp Epidemiol. 2001;22:604
Presented by E. Patchen Dellinger, M.D.
Professor and Vice Chairman, Department of Surgery
Chief, Division of General Surgery
WSHA Safe Table: Reduction of SSI July 10, 2012
Hyperglycemia and Risk of SSI after
Cardiac Operations
• Hyperglycemia - doubled risk of SSI
• Hyperglycemic:
48% of diabetics
12% of nondiabetics
30% of all patients
• 47% of hyperglycemic episodes were in
nondiabetics
Latham. Inf Contr Hosp Epidemiol. 2001;22:607
Dellinger. Inf Contr Hosp Epidemiol. 2001;22:604
Presented by E. Patchen Dellinger, M.D.
Professor and Vice Chairman, Department of Surgery
Chief, Division of General Surgery
WSHA Safe Table: Reduction of SSI July 10, 2012
% Deep Sternal Infection
Deep Sternal SSI and Glucose
8
7
6
5
4
3
2
1
0
100-150
150-200
200-250
Day 1 Glucose (mg%)
Presented by E. Patchen Dellinger, M.D.
Professor and Vice Chairman, Department of Surgery
Chief, Division of General Surgery
WSHA Safe Table: Reduction of SSI July 10, 2012
250-300
Zerr. Ann Thorac Surg
1997; 63:356
Glucose Control and Deep
Sternal Wound Infections
Furnary et al. Ann Thorac Surg
1999:67:352
Presented by E. Patchen Dellinger, M.D.
Professor and Vice Chairman, Department of Surgery
Chief, Division of General Surgery
WSHA Safe Table: Reduction of SSI July 10, 2012
Glucose Control and Mortality after
CABG in 3554 Diabetics
Furnary. J Thorac Cardiovasc Surg
2003;125:1007
Presented by E. Patchen Dellinger, M.D.
Professor and Vice Chairman, Department of Surgery
Chief, Division of General Surgery
WSHA Safe Table: Reduction of SSI July 10, 2012
Early (48h) Postoperative Glucose
Levels and SSI after Vascular Surgery
>151 mg%
117-151 mg%
103-117 mg%
<103 mg%
Vriesendorp. Eur J Vasc Endovasc
Surg 2004; 28:520-5
Presented by E. Patchen Dellinger, M.D.
Professor and Vice Chairman, Department of Surgery
Chief, Division of General Surgery
WSHA Safe Table: Reduction of SSI July 10, 2012
Perioperative Hyperglycemia in
Noncardiac Surgical Patients: Does
it Increase Postoperative Infections?
Postop inf = pneumonia, SSI, UTI, sepsis within 30 d
Variables = postop gluc, age, race, diabetes, ASA,
emergent, op duration, transfusion
Significant:
postop gluc > 180 O.R.=2.03
gluc increase of 40 O.R.=1.9
ASA & emergent
Ramos. Ann Surg 2008;248: 585–591
Presented by E. Patchen Dellinger, M.D.
Professor and Vice Chairman, Department of Surgery
Chief, Division of General Surgery
WSHA Safe Table: Reduction of SSI July 10, 2012
Mastectomy, Hyperglycemia, and SSI
260 patients, 5 glucose determinations (pre-op, at
anesthesia induction, intra-op, in PACU, at 24 hrs)
•Risk Factor
•Age > 50
•Pre-Op ChemoRads
•Any gluc > 150 mg%
Odds
Ratio
3.7
2.8
2.9
C.I.
(1.5-9.2)
(1.4-5.8)
(1.2-6.2)
Villar-Compte. AJIC 2008; 36:192-8
Presented by E. Patchen Dellinger, M.D.
Professor and Vice Chairman, Department of Surgery
Chief, Division of General Surgery
WSHA Safe Table: Reduction of SSI July 10, 2012
Postop Glucose (within 48h) and SSI
Relative Risk
14
12
10
8
6
4
2
0
< 110
111-140
141-180
Glucose
Presented by E. Patchen Dellinger, M.D.
Professor and Vice Chairman, Department of Surgery
Chief, Division of General Surgery
WSHA Safe Table: Reduction of SSI July 10, 2012
181-220
> 220
Ata. Arch Surg 2010:
145: 858-864
Postoperative Glucose and Mortality
in Noncardiac Surgery
Hyperglycemia in nondiabetic patients
was more dangerous than
hyperglycemia in diabetics!
Frisch. Diabetes Care. 2010; 33: 1883-8
Presented by E. Patchen Dellinger, M.D.
Professor and Vice Chairman, Department of Surgery
Chief, Division of General Surgery
WSHA Safe Table: Reduction of SSI July 10, 2012
Rabbit 2 Study – Surgery
Basal/Bolus vs Sliding Scale Insulin
Patients
Mean Fasting
Mean Daily
Readings < 140
Wound infections
Any complication
Basal Bolus
104
155
157
53%
3
9
Sliding Scale
107
167
176
31%
11
26
p value
0.04
.001
.001
.05
.003
Umpierrez. Diabetes Care 2011; 34: 256-61
Presented by E. Patchen Dellinger, M.D.
Professor and Vice Chairman, Department of Surgery
Chief, Division of General Surgery
WSHA Safe Table: Reduction of SSI July 10, 2012
SCOAP Data on Perioperative
Glucose Levels and Insulin Use
• 11630 patients from 2005-2010 with
 Bariatric operation (5360)
 Colectomy (6273)
• Who either
 Experienced hyperglycemia [glucose > 180] (3383)
 Or did not (8247)
• During the perioperative period or on
POD 1 or POD 2
SCOAP data courtesy of Sung (Steve) Kwon
Presented by E. Patchen Dellinger, M.D.
Professor and Vice Chairman, Department of Surgery
Chief, Division of General Surgery
WSHA Safe Table: Reduction of SSI July 10, 2012
SCOAP Data on Perioperative
Glucose Levels and Insulin Use
• Diabetic pts
 Hyperglycemic
• Nondiabetic pts
 Hyperglycemic
4098 (35%)
2369 (58%)
7532 (65%)
1014 (13%)
•30% of all hyperglycemic patients
were not diabetic!
SCOAP data courtesy of Sung (Steve) Kwon
Presented by E. Patchen Dellinger, M.D.
Professor and Vice Chairman, Department of Surgery
Chief, Division of General Surgery
WSHA Safe Table: Reduction of SSI July 10, 2012
Hyperglycemia vs No Hyperglycemia
All Patients
16
14
12
10
8
6
4
2
0
All p<0.01
Normal
Gluc>180
All Pts
Bariatric
Colectomy
SCOAP data courtesy of Sung (Steve) Kwon
Presented by E. Patchen Dellinger, M.D.
Professor and Vice Chairman, Department of Surgery
Chief, Division of General Surgery
WSHA Safe Table: Reduction of SSI July 10, 2012
Hyperglycemia vs No Hyperglycemia
Diabetic Patients
14
* p<0.05
** p<0.01
12
10
8
6
Normal
**
Gluc>180
4
2
0
Both Ops
Bariatric
Colectomy
SCOAP data courtesy of Sung (Steve) Kwon
Presented by E. Patchen Dellinger, M.D.
Professor and Vice Chairman, Department of Surgery
Chief, Division of General Surgery
WSHA Safe Table: Reduction of SSI July 10, 2012
Hyperglycemia vs No Hyperglycemia
Nondiabetic Patients
20
15
All p<0.01
Normal
10
Gluc>180
5
0
All Pts
Bariatric
Colectomy
SCOAP data courtesy of Sung (Steve) Kwon
Presented by E. Patchen Dellinger, M.D.
Professor and Vice Chairman, Department of Surgery
Chief, Division of General Surgery
WSHA Safe Table: Reduction of SSI July 10, 2012
Composite Infection in Hyperglycemic
Patients With and Without Use of Insulin
Odds Ratios
2.5
2
1.5
1
0.5
0
No Insulin
Insulin
SCOAP data courtesy of Sung (Steve) Kwon
Presented by E. Patchen Dellinger, M.D.
Professor and Vice Chairman, Department of Surgery
Chief, Division of General Surgery
WSHA Safe Table: Reduction of SSI July 10, 2012
Operative Reintervention in Hyperglycemic
Patients With and Without Use of Insulin
Odds Ratios
2.5
2
1.5
1
0.5
0
No Insulin
Insulin
SCOAP data courtesy of Sung (Steve) Kwon
Presented by E. Patchen Dellinger, M.D.
Professor and Vice Chairman, Department of Surgery
Chief, Division of General Surgery
WSHA Safe Table: Reduction of SSI July 10, 2012
Mortality in Hyperglycemic Patients
With and Without Use of Insulin
Odds Ratios
3.5
3
2.5
2
1.5
1
0.5
0
No Insulin
Insulin
SCOAP data courtesy of Sung (Steve) Kwon
Presented by E. Patchen Dellinger, M.D.
Professor and Vice Chairman, Department of Surgery
Chief, Division of General Surgery
WSHA Safe Table: Reduction of SSI July 10, 2012
Glucose Levels & SSI
• The exact “best” level of glucose control is unknown
• High glucose levels unequivocally increase the risk of
SSI and other complications
• Tight glucose control is tricky
• Hypoglycemia increases the risk of morbidity and mortality
• But appears quite rarely
• 2 main models for effective glycemic control
• Basal bolus
• Continuous infusion
Presented by E. Patchen Dellinger, M.D.
Professor and Vice Chairman, Department of Surgery
Chief, Division of General Surgery
WSHA Safe Table: Reduction of SSI July 10, 2012
Glucose Control Algorithms
• The Rabbit 2 basal bolus protocol is online at
http://care.diabetesjournals.org/lookup/suppl/d
oi:10.2337/dc10-1407/-/DC1
• The Society of Hospital Medicine Glycemic
Control Resource room contains links to multiple
insulin infusion protocols at
http://www.hospitalmedicine.org/ResourceRoom
Redesign/html/12Clinical_Tools/04_Insulin_Orde
rsIV.cfm
Presented by E. Patchen Dellinger, M.D.
Professor and Vice Chairman, Department of Surgery
Chief, Division of General Surgery
WSHA Safe Table: Reduction of SSI July 10, 2012
Rabbit 2 Protocols
Presented by E. Patchen Dellinger, M.D.
Professor and Vice Chairman, Department of Surgery
Chief, Division of General Surgery
WSHA Safe Table: Reduction of SSI July 10, 2012
Rabbit 2 Protocols
Presented by E. Patchen Dellinger, M.D.
Professor and Vice Chairman, Department of Surgery
Chief, Division of General Surgery
WSHA Safe Table: Reduction of SSI July 10, 2012
Rabbit 2 Protocols
Presented by E. Patchen Dellinger, M.D.
Professor and Vice Chairman, Department of Surgery
Chief, Division of General Surgery
WSHA Safe Table: Reduction of SSI July 10, 2012
Rabbit 2 Protocols
Presented by E. Patchen Dellinger, M.D.
Professor and Vice Chairman, Department of Surgery
Chief, Division of General Surgery
WSHA Safe Table: Reduction of SSI July 10, 2012
Rabbit 2 Protocols
Presented by E. Patchen Dellinger, M.D.
Professor and Vice Chairman, Department of Surgery
Chief, Division of General Surgery
WSHA Safe Table: Reduction of SSI July 10, 2012
I.V. Insulin Infusion Protocol
Presented by E. Patchen Dellinger, M.D.
Professor and Vice Chairman, Department of Surgery
Chief, Division of General Surgery
WSHA Safe Table: Reduction of SSI July 10, 2012
I.V. Insulin Infusion Protocol
Presented by E. Patchen Dellinger, M.D.
Professor and Vice Chairman, Department of Surgery
Chief, Division of General Surgery
WSHA Safe Table: Reduction of SSI July 10, 2012
I.V. Insulin Infusion Protocol
Presented by E. Patchen Dellinger, M.D.
Professor and Vice Chairman, Department of Surgery
Chief, Division of General Surgery
WSHA Safe Table: Reduction of SSI July 10, 2012
I.V. Insulin Infusion Protocol
Presented by E. Patchen Dellinger, M.D.
Professor and Vice Chairman, Department of Surgery
Chief, Division of General Surgery
WSHA Safe Table: Reduction of SSI July 10, 2012
I.V. Insulin Infusion Protocol
Presented by E. Patchen Dellinger, M.D.
Professor and Vice Chairman, Department of Surgery
Chief, Division of General Surgery
WSHA Safe Table: Reduction of SSI July 10, 2012