Rachel E. Thompson

Importance of perioperative glycemic control in general surgery: A report from the surgical care and outcomes assessment program

Objective:To determine the relationship of perioperative hyperglycemia and insulin administration on outcomes in elective colon/rectal and bariatric operations. Background:There is limited evidence to characterize the impact of perioperative hyperglycemia and insulin on adverse outcomes in patients, with and without diabetes, undergoing general surgical procedures. Methods:The Surgical Care and Outcomes Assessment Program is a Washington State quality improvement benchmarking-based initiative. We evaluated the relationship of perioperative hyperglycemia (>180 mg/dL) and insulin administration on mortality, reoperative interventions, and infections for patients undergoing elective colorectal and bariatric surgery at 47 participating hospitals between fourth quarter of 2005 and fourth quarter of 2010. Results:Of the 11,633 patients (55.4 ± 15.3 years; 65.7% women) with a serum glucose determination on the day of surgery, postoperative day 1, or postoperative day 2, 29.1% of patients were hyperglycemic. After controlling for clinical factors, those with hyperglycemia had a significantly increased risk of infection [odds ratio (OR) 2.0; 95% confidence interval (CI), 1.63–2.44], reoperative interventions (OR, 1.8; 95% CI, 1.41–2.3), and death (OR, 2.71; 95% CI, 1.72–4.28). Increased risk of poor outcomes was observed both for patients with and without diabetes. Those with hyperglycemia on the day of surgery who received insulin had no significant increase in infections (OR, 1.01; 95% CI, 0.72–1.42), reoperative interventions (OR, 1.29; 95% CI, 0.89–1.89), or deaths (OR, 1.21; 95% CI, 0.61–2.42). A dose-effect relationship was found between the effectiveness of insulin-related glucose control (worst 180–250 mg/dL, best <130 mg/dL) and adverse outcomes. Conclusions:Perioperative hyperglycemia was associated with adverse outcomes in general surgery patients with and without diabetes. However, patients with hyperglycemia who received insulin were at no greater risk than those with normal blood glucoses. Perioperative glucose evaluation and insulin administration in patients with hyperglycemia are important quality targets.

β-Blocker Continuation After Noncardiac Surgery: A Report From the Surgical Care and Outcomes Assessment Program

BACKGROUND Despite limited evidence of effect, β-blocker continuation has become a national quality improvement metric. OBJECTIVE To determine the effect of β-blocker continuation on outcomes in patients undergoing elective noncardiac surgery. DESIGN, SETTING, AND PATIENTS The Surgical Care and Outcomes Assessment Program is a Washington quality improvement benchmarking initiative based on clinical data from more than 55 hospitals. Linking Surgical Care and Outcomes Assessment Program data to Washingtons hospital admission and vital status registries, we studied patients undergoing elective colorectal and bariatric surgical procedures at 38 hospitals between January 1, 2008, and December 31, 2009. MAIN OUTCOME MEASURES Mortality, cardiac events, and the combined adverse event of cardiac events and/or mortality. RESULTS Of 8431 patients, 23.5% were taking β-blockers prior to surgery (mean [SD] age, 61.9 [13.7] years; 63.0% were women). Treatment with β-blockers was continued on the day of surgery and during the postoperative period in 66.0% of patients. Continuation of β-blockers both on the day of surgery and postoperatively improved from 57.2% in the first quarter of 2008 to 71.3% in the fourth quarter of 2009 (P value <.001). After adjusting for risk characteristics, failure to continue β-blocker treatment was associated with a nearly 2-fold risk of 90-day combined adverse event (odds ratio, 1.97; 95% CI, 1.19-3.26). The odds were even greater among patients with higher cardiac risk (odds ratio, 5.91; 95% CI, 1.40- 25.00). The odds of combined adverse events continued to be elevated 1 year postoperatively (odds ratio, 1.66; 95% CI, 1.08-2.55). CONCLUSIONS β-Blocker continuation on the day of and after surgery was associated with fewer cardiac events and lower 90-day mortality. A focus on β-blocker continuation is a worthwhile quality improvement target and should improve patient outcomes.

Acute traumatic subdural hematoma: Current mortality and functional outcomes in adult patients at a Level I trauma center

BACKGROUND Existing data on outcomes following subdural hematoma have provided limited information on medical complications and functional outcomes. Mortality rates previously reported range from 22% to 66%. METHODS This is a retrospective cohort study of prospectively collected data from a trauma registry in Washington State from 2005 through 2008. Patients were categorized by surgical evacuation status with the hypothesis that those undergoing evacuation represented a more severe injury. RESULTS The 1,427 patients included in the study had a mean age of 58 years, and most of them were male (63%). Glasgow Coma Scale (GCS) score on presentation was greater than 12 in 58%; the average Injury Severity Score (ISS) was 27.5. Mean length of stay was 9.6 days (range, 1–110), with 40% spending 2 or more days in the intensive care unit. Twenty-eight percent experienced medical complications. At discharge, 94% had GCS score of 13 or greater. Independence with expression, feeding, and locomotion at discharge was noted for 92%, 81%, and 43%, respectively. Inpatient mortality was 16% and did not differ significantly between the evacuated group (15%) and the nonevacuated group (17%). CONCLUSION This large cohort of patients with acute traumatic subdural hematoma demonstrated a lower mortality rate than those of previous reports, including among patients requiring surgical evacuation (J Trauma Acute Care Surg. 2012;73:1348–1352). LEVEL OF EVIDENCE Epidemiologic study, level III.

Do Clinicians Know Which of Their Patients Have Central Venous Catheters?: A Multicenter Observational Study

Context Central venous catheters (CVCs) are commonly used to care for hospitalized patients; however, their continued presence creates substantial risks, including infection and thrombosis. Although indwelling CVCs should be removed as soon as they are no longer needed, clinicians may not be aware of their presence. Contribution This study found that many interns, residents, and attending physicians were unaware that their patients had indwelling catheters, including triple-lumen and peripherally inserted central catheters. Implication Increased efforts are needed to ensure that clinicians are mindful of the presence of their patients CVCs. The Editors Central venous catheters (CVCs) are instrumental for the safe and comprehensive care of many hospitalized patients. Often inserted in intensive care unit (ICU) and non-ICU settings, CVCs provide reliable venous access for tasks ranging from hemodynamic monitoring to delivery of irritants, vesicants, and intravenous antibiotics. In adults, 2 devices are most used in this context: nontunneled triple-lumen catheters placed in the subclavian, jugular, or femoral veins and peripherally inserted central catheters (PICCs) inserted into upper-extremity veins (1, 2). Despite their many advantages, triple-lumen catheters and PICCs are associated with important risks, including central lineassociated bloodstream infections (CLABSIs) and venous thromboembolism (3, 4). In particular, PICC-related CLABSI and thromboembolism have recently garnered attention owing to their frequency, attributable cost, and potential for prevention (5, 6). Because the risk for these adverse outcomes increases with time, early removal of CVCs that are no longer clinically warranted is a key strategy for prevention (7, 8). However, accumulating evidence suggests that clinicians often do not remove unnecessary CVCs. For example, a study done at a large academic medical center found many patients with PICCs that were idle and not clinically justifiable (3). In another study, 6.6% of CVCs in non-ICU settings were found to be inappropriate and clinically unnecessary at the time of review (4). These findings are not unique to the United Statesconcerns about inappropriately prolonged use of vascular access devices are well-documented worldwide (912). In survey-based studies of inpatient providers, nearly half of all hospitalists stated that they had, at least once, forgotten that their patient had a PICC in situ (13, 14). These findings mirror trends noted with indwelling urinary catheters, in which 1 in 3 physicians was unaware that these devices were present (15). Given this background, we sought to determine how often interns, residents, general medicine attendings, hospitalists, and subspecialists know which of their hospitalized patients have a PICC or triple-lumen catheter. We hypothesized that clinicians who write orders for or those who are most proximal to patients (for example, interns and hospitalists) would be most likely to correctly identify which of their patients have CVCs. Further, we postulated that clinicians who insert CVCs (such as critical care specialists) or consciously deliberate on the choice of a vascular access device (such as hematologists or oncologists) would be more likely to be aware that a device was present. Methods Patients and Study Population Between April 2012 and September 2013, we conducted face-to-face interviews with hospitalized patients and their responsible clinicians at 3 academic medical centers in the United States. A responsible clinician was defined as an intern, resident, physician extender (for example, nurse practitioner or physician assistant), or attending physician who had provided care to a patient for at least 24 hours. Housestaff were defined as interns (year 1 of training), residents (beyond year 1 of training), or physician extenders who cared for patients under the supervision of an attending physician. At each site, patients and providers were randomly selected from general medicine teaching, hospitalist-only, and subspecialty services that often use CVCs (such as cardiology, gastroenterology and hepatology, hematology and oncology, and critical care) and were primarily responsible for patient care (for example, not consultants). Thus, any provider on duty or patient receiving care in a specialty or discipline of interest was eligible for study inclusion. Eligible patients were identified using electronic patient lists for provider teams at each site. At 2 sites, patients were approached for participation and interviewed for the presence of a CVC. At 1 site, CVCs were identified through use of a validated electronic tool (98% accuracy at correctly identifying CVC presence); these patients were included but not directly examined for device presence. After patients were interviewed or electronically identified, providers were approached to ascertain their awareness of device presence. Clinicians were blinded to which patients were participating in the study and were queried for all patients on their roster. Survey Methods Before morning team rounds, we approached patients to seek written informed consent for participation at 2 of our 3 sites. If patients could not provide consent and a family member was available, consent was obtained from next of kin. Requirement for informed consent was waived at our third site. After consent was obtained, patients were interviewed and a focused examination was done to determine the presence of a PICC or triple-lumen catheter in the jugular, subclavian, or femoral veins at 2 study sites. Central venous catheters were defined as PICCs inserted in any upper-extremity vein or triple-lumen catheters placed in the neck, chest, or groin. Patients with specialty catheters, including hemodialysis catheters, small-bore catheters (such as Pro-Line CTs [Medcomp]), tunneled lines, and midlines were excluded. We surveyed patients in ICU and non-ICU settings; those on surgical services were excluded. Patients were surveyed only once during hospitalization; surveys were done weekly at all sites. After team rounds, we interviewed medical providers for each patient and asked, As of this morning, does your patient have a PICC or a triple-lumen catheter in the neck, chest, or groin? All clinicians were interviewed after morning rounds to ensure that they had seen the patient the day that the survey was administered. Clinicians were interviewed separately and were not notified of our visit beforehand. We allowed clinicians to use such materials as written notes or sign-outs during the interview but they were not allowed access to electronic health records. Because teaching attendings were responsible for all patients on the team, they were queried about CVC presence for all patients on their list. Subspecialists were similarly queried for all patients on their inpatient specialty teams. Interns, residents, and physician extenders were questioned only about patients for whom they were primarily responsible, regardless of assignment to a general medicine or specialist team. All clinicians were surveyed the day that patients were examined. Statistical Analysis Descriptive statistics for patient, provider, device, and site characteristics were used to define the study samples. The primary outcome of interest was unawareness of PICC or triple-lumen catheter presence. Given the categorical nature of the data, differences among provider types and training levels were compared using chi-square tests, where appropriate. Stata MP, version 13.0 (StataCorp), was used for all statistical analyses, and Pvalues less than 0.050 were considered statistically significant. Institutional review boards at each site provided ethical and regulatory approval for the study. Role of the Funding Source The study was not funded by any agency. Results Of the 1082 patients approached, 990 (91.5%) consented to participate in the study. For these 990 patients, we did 1881 clinician assessments across the 3 study sites (Table 1). Clinician responses from interns (454), residents and physician extenders (513), general medicine teaching attendings (245), subspecialty attendings (176), intensivists (95), and hospitalists (398) were included. An average of 1.9 clinician assessments were associated with each patient. Table 1. Patient, Provider, and Site Characteristics The overall prevalence of CVCs (triple-lumen catheter or PICC) was 21.1% (209 of 990). More than one half of the 209 devices were PICCs (n= 126 [60.3%]); the remaining 83 devices were triple-lumen catheters inserted in the neck (n= 41 [19.6%]), chest (n= 24 [11.5%]), or groin (n= 18 [8.6%]). A total of 47.0% (39 of 83) of triple-lumen catheters were found in patients in ICU settings; conversely, 92.9% (117 of 126) of PICCs were found in non-ICU patients. For the 209 patients with CVCs, 21.2% (90 of 425) of responsible clinicians were unaware of the presence of a triple-lumen catheter or PICC (Table 2). Unawareness of PICCs was greatestmore than 1 in 4 responsible clinicians (25.1% [60 of 239]) were not aware of their presence. Lack of awareness of a triple-lumen catheter or PICC varied from 16.3% to 31.1% across sites (P= 0.038) and was most pronounced in non-ICU settings, where PICCs are most common (24.8% vs. 12.6% in non-ICU and ICU settings; P= 0.005). Of note, a small but substantial number of clinicians (5.6% [82 of 1456]) stated that their patients had a CVC when no device was found on examination. Table 2. Awareness of CVC Presence We tested whether proximity to patients was associated with awareness of device presence. Although interns were the clinicians most likely to write orders, almost 1 of every 5 surveyed was not aware that his or her patient had a triple-lumen catheter or PICC (19.1% [22 of 115]). Although medical residents were more frequently aware of device presence than interns, the difference did not reach statistical significance (13.8% vs. 19.1%; P= 0.27). However, teaching

Improving insulin ordering safely: the development of an inpatient glycemic control program.

This report describes a Glycemic Control Program instituted at an academic regional level-one trauma center. Key interventions included: 1) development of a subcutaneous insulin physician order set, 2) use of a real-time data report to identify patients with out-of-range glucoses, and 3) implementation of a clinical intervention team. Over four years 18,087 patients admitted to non-critical care wards met our criteria as dysglycemic patients. In this population, glycemic control interventions were associated with increased basal and decreased sliding scale insulin ordering. No decrease was observed in the percent of patients experiencing hperglycemia. Hypoglycemia did decline after the interventions (4.3% to 3.6%; p = 0.003). Distinguishing characteristics of this Glycemic Control Program include the use of real-time data to identify patients with out-of-range glucoses and the employment of a single clinician to cover all non-critical care floors.

Efficacy of diabetes nurse expert team program to improve nursing confidence and expertise in caring for hospitalized patients with diabetes mellitus

Nursing care for hospitalized patients with diabetes has become more complex as evidence accumulates that inpatient glycemic control improves outcomes. Previous studies have highlighted challenges for educators in providing inpatient diabetes education to nurses. In this article, the authors show that a unit-based diabetes nurse expert team model, developed and led by a diabetes clinical nurse specialist, effectively increased nurses’ confidence and expertise in inpatient diabetes care. Adapting this model in other institutions may be a cost-effective way to improve inpatient diabetes care and safety as well as promote professional growth of staff nurses.

Point-of-care blood glucose measurement errors overestimate hypoglycaemia rates in critically ill patients

Hypoglycaemia is associated with morbidity and mortality in critically ill patients, and many hospitals have programmes to minimize hypoglycaemia rates. Recent studies have established the hypoglycaemic patient‐day as a key metric and have published benchmark inpatient hypoglycaemia rates on the basis of point‐of‐care blood glucose data even though these values are prone to measurement errors.

Perioperative Glycemic Control During Colorectal Surgery

Hyperglycemia occurs frequently among patients undergoing colorectal surgery and is associated with increased risk of poor clinical outcomes, especially related to surgical site infections. Treating hyperglycemia has become a target of many enhanced recovery after surgery programs developed for colorectal procedures. There are several unique considerations for patients undergoing colorectal surgery including bowel preparations and alterations in oral intake. Focused protocols for those with diabetes and those at risk of hyperglycemia are needed in order to address the specific needs of those undergoing colorectal procedures.

Evaluation of Point-of-Care Blood Glucose Measurements in Patients with Diabetic Ketoacidosis or Hyperglycemic Hyperosmolar Syndrome Admitted to a Critical Care Unit

Background: Point-of-care (POC) blood glucose (BG) measurement is currently not recommended in the treatment of patients presenting with diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar syndrome (HHS). Methods: We prospectively evaluated and compared capillary and venous POC BG values with laboratory venous glucose in patients with DKA or HHS admitted to one critical care unit over 8 months. Results: Venous laboratory glucose was strongly correlated with venous (r = 0.98) and capillary (r = 0.96) POC glucose values, though POC glucose values were higher than venous laboratory values (venous POC 21 ± 3 mg/dl, capillary POC 30 ± 4 mg/dl; both p < .001). Increased plasma osmolality had no effect on glucose meter error, while acidemia (pH < 7.3) was associated with greater glucose meter error (p = .04) independent of glucose levels. Comparing hypothetical insulin infusion rates based on laboratory venous glucose to actual infusion rates based on POC glucose values showed that 33/61 insulin infusion rates would have been unchanged, while 28 out of 61 rates were on average 7% ± 2% higher. There were no instances of hypoglycemia in any of the patients. Conclusions: Overall, both venous and capillary POC BG values were safe for the purpose of titrating insulin infusions in patients with severe hyperglycemia. Acidemia, but not hyperosmolality, increased POC BG value errors.

Primary lesion of multiple myeloma presenting as gingival swelling

It is rare that multiple myeloma (MM) occurs as a primary lesion in the jaws; we report such a case in an elderly patient involving the gingiva of the left posterior mandible. Multiple myeloma is a monoclonal malignant neoplasm of plasma cell origin which occurs in the bone marrow and may result in extensive destruction of skeletal structures. If the jaws are involved, it usually indicates an advanced stage of the disease.Thi s makes our case very unique due to the fact no other osteolytic lesions were identified at the time of the diagnosis of multiple myeloma. We report a rare case of multiple myeloma which was diagnosed from an intraoral gingival lesion on the lower left mandible.