Implementation Plan

MISSION STATEMENT














The threefold mission of the perioperative dept at our facility is to first strive to achieve safe, successful surgical intervention, second to promote an uneventful phase 1 post operative recovery with the minimal discomfort possible, and third to enable the client and his caregivers to provide a continued effective recovery upon admission to post operative phase II. For the diabetic population this is particularly challenging. External evaluation of evidence based research clearly demonstrates a direct correlation between elevated glucose levels and postoperative complications, manifested by delayed wound healing and increased incidence of infections (Allen 2008, Maser 1996, Mathias 2007, Moghissi 2009, Wellard 2007). Research further suggests the standardized practice of monitoring blood glucose levels every 1 to 2 hours intraoperatively, as stress induced hyperglycemia is the body’s expected response (Furnary 1999, Maser, Moghissi). The ADA recommended range is 140 to 180 mg dL under physiologically stressed conditions and 100 to 140 under normal inpatient stress conditions (Moghissi).

Product Selection
A continuous glucose monitoring device (CGMD) should provide early detection of undesirable hypoglycemic events and ultimately avert postoperative complications secondary to hyperglycemia (Allen, George 2009, Magee 2007, Mathias,). CGMD’s are a recent innovation. Of the 3 FDA approved devices we investigated, we have selected the Seven Plus from DexCom, who offers an excellent product and superior vendor service in addition to being the only major medical manufacturer company solely dedicated to diabetic management (dexCom.com).

Planning Phase of Implementation Plan
The planning phase will be under the direction of a multidisciplinary team of perioperative and diabetic nurse educators with input from clinical II and III staff RN’s, in addition to selected anesthesiologists, endocrinologists, and pharmacists. Materials management and the DexCom vendors will be also utilized. Step one will be preparation. The current policies and procedures for point of care accuchecks will be revised to temporarily coincide with the Seven Plus CGM. A policy and procedure will be created specifically for patients receiving CGM, including the insertion, maintenance and interpretation of the receiver monitor read outs according to manufacture guidelines. Patient selection criteria for the initial phase will be defined utilizing the ranges of the Body Mass Index (BMI) of Diabetic Type II patients, proposed length of surgery, and type of anesthesia.

Go Live Step 1
Nursing preparation will include education and instruction. Education will include a review class about diabetes management, the postoperative complications associated with hyperglycemia, and the signs and symptoms of hypoglycemia. A review of the current policy and procedure for point of care testing and insulin administration will be followed with the additional CGM policy. An instruction video will demonstrate proper technique for probe insertion, receiver calibration, trend reading, and wave form interpretation of a malfunctioning probe with trouble shooting techniques, along with concise documentation for all of the above. An on-line written test via the education web site covering these topics will be given. After passing the test, simulated hands-on training with return demonstrations of proficiency will commence with the superusers being trained prior to their peers.

Go live Step II
The initial go live phase will be implemented by parallel conversion on a limited number of patients who meet selection criteria. On site vendor support will be ongoing during the first three days. Staffing of the affected units will be increased by 20% and super users will not be given regular patient assignments for the first 2 weeks.
During the first 2 weeks, in addition to following CGM policy and procedure guidelines, glucose levels will be monitored by point of care accuchecks every 2 hours from the start of the surgical procedure for a total of 8 hours, and then every 4 hours according to current policy. Any hypoglycemia or hyperglycemia trending, or suspect clinical manifestations, will be verified with an accuheck and treated according to diabetic algorithm protocol as prescribed by the involved endocrinologists.
Internal evaluation will first be made at the end the 2 weeks, including a comparison of CGM and simultaneous accucheck readings. If the discrepancies of the interstitial glucose levels are consistently within the expected 20 percentile range of error, the patient selection criteria will be expanded to include all Type II diabetics undergoing general anesthesia with an expected 23 hour observation stay. The bihourly accuchecks will revert to the prior practice of pre and post surgical and every 4 hours thereafter for the next 45 days, again comparing and recording readings between devices. This will allow time for careful scrutiny of the Seven Plus CGMD and promote maximum nurse proficiency with the product. Any suspect reading or symptoms from the patient will still warrant a point of care accucheck at any time between scheduled readings. Another internal evaluation of the product including the nursing staff will be made at the end of 45 days. If the goal of achieving tighter glucose control is overall effective, then the policy will be updated to the manufacture recommendation of accuchecks only being checked every 12 hours.

Case Study
A study was done in 2007 to assess the reliability and accuracy of CGM compared to blood glucose levels during surgery. 29 patients undergoing major scheduled surgeries were participants. An arterial line was inserted and frequent blood glucose monitoring occurred throughout the surgery. 100 samples were compared and the lower and upper limits of blood glucose coincided to interstitial CGM at 21% and 18% respectively” (Yamashita 2008). This evidence based study confirms the manufacture’s claim of CGM device reliability during the perioperative experience, in addition to the benefit afforded to diabetic patients by the value of constant observance of glucose trends and ultimately a decrease in uncomfortable finger sticks (dexCom.com).




Reference List:

Allen, G (2008). Evidence for practice. Continuous blood glucose monitoring during surgery. AORN Journal, 87(5), 1016-1017.

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.

Mathias, J. (2007). Aiming for tighter glucose control…this article originally appeared in the September 2006 OR Manager. OR Manager, 10-12.

Moghissi, E.S. MD, Korytkowski, M.T. MD, DiNardo, M. MSN, Hirsch, Irl B. MD, Inzuchi S.E. MD, Ismail-Beigi, F. MD (MayJune 2009). American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement of an inpatient glycemic control. Endocrine Practice, Vol 15 (4), 1-10

Wellard, Sally J. RN PHD, Cox, Helen RN PhD, Bhujoharry, Claire BN (2007). Issues in the provision of nursing care to people undergoing cardiac surgery who also have type 2 diabetes. International Journal of Nursing Practice 2007; 13: 222-

Furnary, A.P., Zer, K.J., Grunkemeier, GL (1999). Landmark studies on glucose control: risk of hyperglycemia. Annual of Thoracic Surgery 1999; 67:352-362
George, Christa M. (2009) Future Trends in Diabetes Management. American Nephrology Nurses’ Association, 36(5), 477-483

Magee, M. (2007). Hospital protocols for targeted glycemic control: development, I mplementation, and models for cost justification. American Journal of Health-System Pharmacy, 64S, 15-23

DexCom, http://www.dexcom.com/

Yamashita K., Okabayashi T. (2008). The accuracy of a continuous blood glucose monitor during surgery. Anesthesia Analogue 2008; 106 (1), 160-163