Cardiac Glucose Control

Purpose:
To improve glucose control in the postoperative cardiac surgery patient. The baseline compliance was 85% with a Sigma Score of 2.56 and 145,454 defects per million opportunity (DPMO).

Significance:
Controlled blood glucose in the postoperative cardiac patient is endorsed by the NQF. Hyperglycemia is associated with increased mortality and increased risk of infection. It is a surgical care improvement project indicator, publically reported & part of the value based purchasing program.

Strategy and Implementation:
A negative trend was identified with acheiving consistant glucose control in postoperative cardiac patients. We have recently begin using principles of Lean Six-Sigma performance improvement DMAIC methodology. DEFINE: A glucose protocol was being used, but voice of the customer (both physicians & nurses) revealed that it was confusing and opened to a large variation of interpretation. MEASURE: A baseline measure revealed a poor process capability of a 14.5% defect rate, Sigma Score of 2.56 & DPMO of 145,454. ANALYZE: Chi Square analysis was done with root causes identified as: variation in insulin ordering practices of consulting MDs, recommended dose on protocol not AACE recommended, knowledge deficit lead to hesitation to give Lantus in recommended dose, & hospitalist scale on telemetry was ineffective. IMPROVE:The interdisciplinary team worked to develop a revised, clearer protocol in both the ICU & Telemetry. Consideration was given to the nurses workflow.

Evaluation:
We have improved from 85% to 97% compliant with glucose ≤200, from a DPMO of 145,455 to a DMPO of 34,091 & from a Sigma Score of 2.56 to a Sigma Score of 3.32. The staffs are please. We continue monitor & revised as need to reach a Sigma Score of 6.0!

Implications for Practice:
Evidence indicates that strict compliance with this & other SCIP elements will result in the reduction or elimination of surgical infections. Use of the protocol has standardized the postopoerative treatment of glucose control in the ICU & Telemetry and lead to less confusion of treatment options.