Strategic Planning of
Implementing Continuous Glucose Monitoring in the
Surgical Patient Population
Aim of the Project
The aim of this project is to achieve the standardized practice of implementing a continuous glucose monitoring device on all diabetics experiencing surgery at Hoag Hospital. The ultimate goal being a reduction in the risks and complications secondary to hyperglycemia which currently prolong hospital stays.
Outline of the Project
Upon admission to the Post Anesthesia Care Unit, all known and suspected diabetics, (i.e. those with abnormally elevated glucose levels in their presurgical blood work) will have their glucose levels monitored with the traditional finger stick method, noting pre and post operative level disparities to clearly define the problem. An MD order will need to be obtained to perform any accuchecks not already ordered.
A data collection sheet will be created to log the results of pre and post operative glucose levels, as well as any done intraoperatively. On each of these patients the times of the glucose level checks, along with the dosage and time of any insulin will be noted in the survey. In addition, the ordered frequency of postoperative glucose monitoring will also be recorded. Surgical start and finish times will be documented. This study will commence over a 10 day period, with at least 25 patients monitored, or until 25 patients are studied. Upon the conclusion of this collection of data, pre and post operative sugars will be correlated to the length and type of surgery.
Simultaneous to the above mentioned data collection; external research will be conducted on the potential choices of continuous monitoring devices. A thorough investigation of products available via the internet and the EBSCO library at Vanguard, in addition to recommendations or endorsements by the American Diabetic Association or the American Association of Clinical Endocrinologists will be conducted. Letters and personal interviews with vendors of the various companies selling these products will also take place. The vendor interviews will include a discussion of the application and usage of their product, in addition to the projected expense and feasibility of implementation to the clients and /or hospital. If possible, samples of product options will be procured from the vendors as well.
The culmination of the above external and internal research will first be presented to the perioperative staff of anesthesiologists and nurses, along with the perioperative nurse educators and managers in an informal presentation. A vendor of the most favored product will hopefully be a part of the presentation. If possible, any samples of products will be shared. The pros and cons of the different devices will be demonstrated. In addition to the presentation of the various devices, the evidence procured by the results of the patient glucose monitoring study will be displayed. If indeed the random data collection concludes there is a marked elevation of glucose relative to the surgical type and length, the need for intraoperative monitoring will be particularly stressed.
A power point presentation of all of the above mentioned efforts will be presented to the nursing informatics class.
Tuesday, March 30, 2010
Monday, March 29, 2010
Statement of the Problem
One in five patients over the age of 60 is a diabetic (Gavi & Hensley 2009). One in five of all patients admitted for surgery are undiagnosed diabetics (Mathias 2007). In view of these statistics, the patient population requiring glucose monitoring during surgical admissions will predictably increase. The current practice of multiple finger sticks for glucose samples throughout the perioperative experience is uncomfortable for the patient, an additional task for already busy nurses, and logistically challenging intraoperatively. A continuous glucose monitoring device placed on the patient preoperatively could alleviate patient discomfort, avoid delays of treatment, and avert many postoperative complications secondary to hyperglycemia.
Review of the Literature
Research suggests that because of the acute hyperglycemia which occurs intraoperatively, in known or suspected diabetics, glucose levels should be monitored every 1 to 2 hrs throughout the surgery (Maser, Ellers & Decherney 1996). However with the patient’s hands relatively inaccessible while covered under sterile drapes, glucose testing tends to be delayed until the patient reaches Phase I recovery, resulting in “chasing” elevated blood sugars with insulin injections (Allen 2008).
For the diabetic patient undergoing surgery, this acute hyperglycemic reaction puts him at risk for many complications. Intraoperatively, cardiovascular or neurological complications may occur (Maser, Ellers & Decherney 1996). Postoperative sustained blood glucose levels above 250 mg dL result in prolonged hospital stays due to delayed wound healing, and infections (Maser, Ellers & Decherney). The American Diabetic Association recommended in 2009 that glucose levels of critically ill patients be maintained between 140 and 180 mg dL(). In another study the recommended blood sugar intraoperatively was between 180 and 200 mg dL (Mathias 2007) . Therefore stringent monitoring of glucose levels throughout the perioperative process of diabetic patients is imperative to averting undesirable medical or surgical outcomes.
A continuous glucose monitoring device could prevent undetected detrimental glucose swings while lessoning the work load of the nursing staff. Currently there are 7 FDA approved devices on the market which are usually combined with an insulin pump (George 2009). Continuous glucose monitoring is now being utilized in some facilities during hospitalized labor and delivery on diabetic mothers (Stenninger & Lindqvist 2008). Subcutaneous glucose monitoring “Involves placing a glucose oxidase-based electrochemical sensor beneath the skin once every 3 to 7 days. The sensor measures interstitial glucose levels at regular intervals and transmits them wirelessly to a receiver where they are stored” (George 2009).
Aim of the Project
The aim of this project is to decrease the frequency of intermittent finger sticking for glucose results, while achieving continuous glucose monitoring throughout the hospital stay. The desired outcome being glucose levels of diabetics are maintained within the ADA recommended range of 140 to 160 mg dL as deviations will be promptly recognized and treated. The risks and complications secondary to hyperglycemia will be averted, and hospital stays will be shortened.
Outline of the Project
The first step will be to monitor glucose levels on patients who admit to the PACU, noting pre and post operative level disparities to clearly define the problem. Length of surgery will also be noted in addition to insulin requirements. This will be done over a 10 day period. As results are accumulating, external research will be conducted on the potential choices of continuous monitoring devices, the expense and feasibility of implementation. Ongoing internal assessments through casual interviews with anesthesiologists and perioperative coworkers will be performed throughout the process. Samples of product options will be procured and through the help of vendors, a trial run may be implemented if approval can be obtained from the unit managers and anesthesiologists. Results of these efforts will be presented to the perioperative staff and the nursing informatics class.
Reference list
Gavi, Shai, MD & Hensley, Jennifer, MD (2009). Diagnosis and management of type 2 diabetes in adults: A review of the ICSI guideline. Geriatrics , 64(6)
Mathias, J. (2007). Aiming for tighter glucose control... this article originally appeared in the September 2006 OR Manager. OR Manager, 10-12.
Maser, R., Ellers, J., & DeCherney, G. (1996). Glucose monitoring of patients with diabetes mellitus receiving general anesthesia: a study of the practices of anesthesia providers in a large community hospital. AANA Journal, 64(4), 357-361. Retrieved from CINAHL with Full Text database.
Allen, G. (2008). Evidence for practice. Continuous glucose monitoring during surgery. AORN Journal, 87(5) 1016 -1017
Review of the Literature
Research suggests that because of the acute hyperglycemia which occurs intraoperatively, in known or suspected diabetics, glucose levels should be monitored every 1 to 2 hrs throughout the surgery (Maser, Ellers & Decherney 1996). However with the patient’s hands relatively inaccessible while covered under sterile drapes, glucose testing tends to be delayed until the patient reaches Phase I recovery, resulting in “chasing” elevated blood sugars with insulin injections (Allen 2008).
For the diabetic patient undergoing surgery, this acute hyperglycemic reaction puts him at risk for many complications. Intraoperatively, cardiovascular or neurological complications may occur (Maser, Ellers & Decherney 1996). Postoperative sustained blood glucose levels above 250 mg dL result in prolonged hospital stays due to delayed wound healing, and infections (Maser, Ellers & Decherney). The American Diabetic Association recommended in 2009 that glucose levels of critically ill patients be maintained between 140 and 180 mg dL(). In another study the recommended blood sugar intraoperatively was between 180 and 200 mg dL (Mathias 2007) . Therefore stringent monitoring of glucose levels throughout the perioperative process of diabetic patients is imperative to averting undesirable medical or surgical outcomes.
A continuous glucose monitoring device could prevent undetected detrimental glucose swings while lessoning the work load of the nursing staff. Currently there are 7 FDA approved devices on the market which are usually combined with an insulin pump (George 2009). Continuous glucose monitoring is now being utilized in some facilities during hospitalized labor and delivery on diabetic mothers (Stenninger & Lindqvist 2008). Subcutaneous glucose monitoring “Involves placing a glucose oxidase-based electrochemical sensor beneath the skin once every 3 to 7 days. The sensor measures interstitial glucose levels at regular intervals and transmits them wirelessly to a receiver where they are stored” (George 2009).
Aim of the Project
The aim of this project is to decrease the frequency of intermittent finger sticking for glucose results, while achieving continuous glucose monitoring throughout the hospital stay. The desired outcome being glucose levels of diabetics are maintained within the ADA recommended range of 140 to 160 mg dL as deviations will be promptly recognized and treated. The risks and complications secondary to hyperglycemia will be averted, and hospital stays will be shortened.
Outline of the Project
The first step will be to monitor glucose levels on patients who admit to the PACU, noting pre and post operative level disparities to clearly define the problem. Length of surgery will also be noted in addition to insulin requirements. This will be done over a 10 day period. As results are accumulating, external research will be conducted on the potential choices of continuous monitoring devices, the expense and feasibility of implementation. Ongoing internal assessments through casual interviews with anesthesiologists and perioperative coworkers will be performed throughout the process. Samples of product options will be procured and through the help of vendors, a trial run may be implemented if approval can be obtained from the unit managers and anesthesiologists. Results of these efforts will be presented to the perioperative staff and the nursing informatics class.
Reference list
Gavi, Shai, MD & Hensley, Jennifer, MD (2009). Diagnosis and management of type 2 diabetes in adults: A review of the ICSI guideline. Geriatrics , 64(6)
Mathias, J. (2007). Aiming for tighter glucose control... this article originally appeared in the September 2006 OR Manager. OR Manager, 10-12.
Maser, R., Ellers, J., & DeCherney, G. (1996). Glucose monitoring of patients with diabetes mellitus receiving general anesthesia: a study of the practices of anesthesia providers in a large community hospital. AANA Journal, 64(4), 357-361. Retrieved from CINAHL with Full Text database.
Allen, G. (2008). Evidence for practice. Continuous glucose monitoring during surgery. AORN Journal, 87(5) 1016 -1017
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