A Perioperative Systems Design to Improve Intraoperative Glucose Monitoring Is Associated with a Reduction in Surgical Site Infections in a Diabetic Patient Population

Quality Improvement in the Digital Age: The Promise of Using Informatics to Improve Obstetric Anesthesia Care

Informatics describes the study and use of processes for obtaining and utilizing data. In the clinical context, these data are then used to inform and educate providers to improve patient care. In the current digital age, informatic solutions can help clinicians to understand past or current quality issues (afferent tools), to benchmark personal performance against national averages (feedback tools), and to disseminate information to encourage best practice and quality care (efferent tools). There are countless examples of how these tools can be adapted for use in obstetric anesthesia, with evidence to support their implementation. This article thus aimed to summarize the many ways in which informatics can help clinicians to harness the power of data to improve quality and safety in obstetric anesthesia.

A Mobile Post Anesthesia Care Unit Order Reminder System Improves Timely Order Entry

Transition to the postanesthesia care unit (PACU) requires timely order placement by anesthesia providers. Computerized ordering enables automated order reminder systems, but their value is not fully understood. We performed a single-center, retrospective cohort study to estimate the association between automated PACU order reminders and primary outcomes (1) on-time order placement and (2) the degree of delay in placement. As a secondary post-hoc analysis, we studied the association between late order placement and PACU outcomes. We included patients with a qualifying postprocedure order from January 1, 2019, to May 31, 2023. We excluded cases transferred directly to the ICU, whose anesthesia provider was involved in the pilot testing of the reminder system, or those with missing covariate data. Order reminder system usage was defined by the primary attending anesthesiologist's receipt of a push notification reminder on the day of surgery. We estimated the association between reminder system usage and timely order placement using a logistic regression. For patients with late orders, we performed a survival analysis of order placement. The significance level was 0.05. Patient (e.g., age, race), procedural (e.g., anesthesia duration), and provider-based (e.g., ordering privileges) variables were used as covariates within the analyses. Reminders were associated with 51% increased odds of order placement prior to PACU admission (Odds Ratio: 1.51; 95% Confidence Interval: 1.43, 1.58; p ≤ 0.001), reducing the incidence of late PACU orders from 17.5% to 12.6% (p ≤ 0.001). In patients with late orders, the reminders were associated with 10% quicker placement (Hazard Ratio: 1.10; 95% CI 1.05, 1.15; p < 0.001). On-time order placement was associated with decreased PACU duration (p < 0.001), decreased odds of peak PACU pain score (p < 0.001), and decreased odds of multiple administration of antiemetics (p = 0.02). An order reminder system was associated with an increase in order placement prior to PACU arrival and a reduction in delay in order placement after arrival.

Scoping Review: Anesthesiologist Involvement in Alternative Payment Models, Value Measurement, and Nonclinical Capabilities for Success in the United States of America

The US healthcare sector is undergoing significant payment reforms, leading to the emergence of Alternative Payment Models (APMs) aimed at improving clinical outcomes and patient experiences while reducing costs. This scoping review provides an overview of the involvement of anesthesiologists in APMs as found in published literature. It specifically aims to categorize and understand the breadth and depth of their participation, revolving around 3 main axes or "Aims": (1) shaping APMs through design and implementation, (2) gauging the value and quality of care provided by anesthesiologists within these models, and (3) enhancing nonclinical abilities of anesthesiologists for promoting more value in care. To map out the existing literature, a comprehensive search of relevant electronic databases was conducted, yielding a total of 2173 articles, of which 24 met the inclusion criteria, comprising 21 prospective or retrospective cohort studies, 2 surveys, and 1 case-control cohort study. Eleven publications (45%) discussed value-based, bundled, or episode-based payments, whereas the rest discussed non-payment-based models, such as Enhanced Recovery After Surgery (7 articles, 29%), Perioperative Surgical Home (4 articles, 17%), or other models (3 articles, 13%).The review identified key themes related to each aim. The most prominent themes for aim 1 included protocol standardization (16 articles, 67%), design and implementation leadership (8 articles, 33%), multidisciplinary collaboration (7 articles, 29%), and role expansion (5 articles, 21%). For aim 2, the common themes were Process-Based & Patient-Centric Metrics (1 article, 4%), Shared Accountability (3 articles, 13%), and Time-Driven Activity-Based Costing (TDABC) (3 articles, 13%). Furthermore, we identified a wide range of quality metrics, spanning 8 domains that were used in these studies to evaluate anesthesiologists' performance. For aim 3, the main extracted themes included Education on Healthcare Transformation and Policies (3 articles, 13%), Exploring Collaborative Leadership Skills (5 articles, 21%), and Embracing Advanced Analytics and Data Transparency (4 articles, 17%).Findings revealed the pivotal role of anesthesiologists in the design, implementation, and refinement of these emerging delivery and payment models. Our results highlight that while payment models are shifting toward value, patient-centered metrics have yet to be widely accepted for use in measuring quality and affecting payment for anesthesiologists. Gaps remain in understanding how anesthesiologists assess their direct impact and strategies for enhancing the sustainability of anesthesia practices. This review underscores the need for future research contributing to the successful adaptation of clinical practices in this new era of healthcare delivery.

Barriers to High-quality Postoperative Glycemic Management by Surgical Teams: A Theory-informed Qualitative Analysis

OBJECTIVE

Our aim in this study was to identify the barriers to following recommendations for postoperative glycemic management among surgical team members.

METHODS

We conducted semistructured interviews with surgical team members guided by 2 theoretical frameworks for understanding the barriers and drivers of health-care behaviours: the Theoretical Domains Framework and the Consolidated Framework for Implementation Research. Interview data were coded deductively by 2 study team members.

RESULTS

Sixteen surgical team members from 7 surgical disciplines at a single hospital participated in this investigation. The most important barriers to management of postoperative hyperglycemia were knowledge of glycemic targets, belief about consequences of hyper- and hypoglycemia, available resources to manage hyperglycemia, adaptability of usual insulin regimens to complex postoperative patients, and skills to initiate insulin.

CONCLUSIONS

Interventions to reduce postoperative hyperglycemia are unlikely to be effective unless they use implementation science to address local barriers to high-quality management among surgical team members, including setting and systems-level barriers.

Perioperative Glycemic Surveillance and Control-Current Practices, Efficacy and Impact on Postoperative Outcomes following Infrainguinal Vascular Intervention

BACKGROUND

Perioperative glycemic control plays a pivotal role in improving postsurgical outcomes. Hyperglycemia occurs frequently in surgical patients and has been associated with higher rates of mortality and postoperative complications. However, no current guidelines exist regarding intraoperative glycemic monitoring of patients undergoing peripheral vascular procedures and postoperative surveillance is often restricted to diabetic patients. We sought to characterize the current practices around glycemic monitoring and efficacy of perioperative glycemic control at our institution. We also examined the impact of hyperglycemia in our surgical population.

METHODS

This was a retrospective cohort study performed at the McGill University Health Centre and Jewish General Hospital in Montreal, Canada. Patients undergoing elective open lower extremity revascularization or major amputation between 2019 and 2022 were included. Data collected from the electronic medical record included standard demographics, clinical, and surgical characteristics. Glycemic measurements and perioperative insulin use were recorded. Outcomes included 30-day mortality and postoperative complications.

RESULTS

A total of 303 patients were included in the study. Overall, 38.9% of patients experienced perioperative hyperglycemia defined as glucose ≥180 mg/dL (10 mmol/L) during their hospital admission. Only 12 (3.9%) patients within the cohort underwent any intraoperative glycemic surveillance, while 141 patients (46.5%) had an insulin sliding scale prescribed postoperatively. Despite these efforts, 51 (16.8%) patients remained hyperglycemic for at least 40% of their measurements during their hospitalization. Hyperglycemia in our cohort was significantly associated with an increased risk of 30-day acute kidney injury (11.9% vs. 5.4%, P = 0.042), major adverse cardiac events (16.1% vs. 8.6%, P = 0.048), major adverse limb events (13.6% vs. 6.5%, P = 0.038), any infection (30.5% vs. 20.5%, P = 0.049), intensive care unit admission (11% vs. 3.2%, P = 0.006) and reintervention (22.9% vs. 12.4%, P = 0.017) on univariate analysis. Furthermore, multivariable logistic regression including the covariates of age, sex, hypertension, smoking status, diabetic status, presence of chronic kidney disease, dialysis, Rutherford stage, coronary artery disease and perioperative hyperglycemia demonstrated a significant relationship between perioperative hyperglycemia and 30-day mortality (odds ratio [OR]: 25.00, 95% confidence interval [CI]: 2.469-250.00, P = 0.006), major adverse cardiac events (OR: 2.08, 95% CI: 1.008-4.292, P = 0.048), major adverse limb events (OR: 2.24, 95% CI: 1.020-4.950, P = 0.045), acute kidney injury (OR: 7.58, 95% CI: 3.021-19.231, P < 0.001), reintervention (OR: 2.06, 95% CI: 1.117-3.802, P = 0.021), and intensive care unit admission (OR: 3.38, 95% CI: 1.225-9.345, P = 0.019).

CONCLUSIONS

Perioperative hyperglycemia was associated with 30-day mortality and complications in our study. Despite this, intraoperative glycemic surveillance occurred rarely in our cohort and current postoperative glycemic control protocols and management failed to achieve optimal control in a significant percentage of patients. Standardized glycemic monitoring and stricter control in the intraoperative and postoperative period therefore represent an area of opportunity for reducing patient mortality and complications following lower extremity vascular surgery.

PeRiOperative Glucose PRAgMatic (PROGRAM) trial protocol and statistical analysis plan for comparing automated intraoperative reminders to standardise insulin administration in surgical patients at high risk of hyperglycaemia

INTRODUCTION

Studies finding perioperative hyperglycaemia is associated with adverse patient outcomes in surgical procedures spurred the development of blood glucose guidelines at many institutions. In this trial, we will assess the implementation of a clinical decision support tool that is integrated into the intraoperative portion of our electronic health record and provides real-time best practice recommendations for intraoperative insulin dosing in surgical patients at high risk for hyperglycaemia.

METHODS AND DESIGN

We will assess this intervention using a sequential and repeated cross-over design at the institutional level with periods of time for wash-out, control and study intervention. The unit of analysis will be the surgical case. The primary outcome will be the frequency of hyperglycaemia (>180 mg/dL (10 mmol/L)) at first postoperative anaesthesia care unit measurement. There are several prespecified secondary analyses focused on perioperative glycaemic control.

DISCUSSION

This protocol and statistical analysis plan describes the methodology, primary and secondary analyses. The PeRiOperative Glucose PRAgMatic (PROGRAM) trial was approved by the Vanderbilt University Institutional Review Board (IRB), Vanderbilt University Medical Center, Nashville, Tennessee, USA (IRB, 220991). The study results will be disseminated via publication in a peer-reviewed journal and presented at national scientific conferences. The results of PROGRAM trial will inform best practice for perioperative standardised insulin administration in surgical patients at high risk of hyperglycaemia.

TRIAL REGISTRATION NUMBER

NCT05426096.

Strategies to prevent surgical site infections in acute-care hospitals: 2022 Update

The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing their surgical-site infection (SSI) prevention efforts. This document updates the Strategies to Prevent Surgical Site Infections in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

The efficacy of intraoperatie continuous glucose monitoring in patients undergoing liver transplantation: a study protocol for a prospective randomized controlled superiority trial

BACKGROUND

The high incidence of intraoperative glucose dysregulations in liver transplantation (LT) is related to the lack of highly orchestrated control of intraoperative blood glucose. Glucose monitoring based on a single arterial blood gas test can only provide a simple glucose profile and is insufficient in monitoring intraoperative glycemic variability (GV), which is not conducive to controlling GV and may have a lag in the management of hyper/hypoglycemia. Continuous glucose monitor (CGM), which has been successfully applied in the management of chronic disease in diabetes, provides more detailed blood glucose records and reflect GV parameters such as coefficient of variation (CV%). However, its effectiveness and accuracy for guiding blood glucose management in major surgeries remains unclear.

METHODS

This is a single-center, randomized, controlled, superiority trial. One hundred and eighty patients scheduled for orthotopic LT will be recruited and randomized into two groups. All patients are monitored for intraoperative glucose using CGM combined with arterial blood gas (ABG). In the intervention group (group CG), ABG will be performed when CGM value is < 6.1 mmol/L or > 10.0 mmol/L, or the rate of change of CGM value > 1.67 mmol/(L·min). In the control group (group G), intraoperative ABG tests will be performed every 2 h, and the frequency of ABG tests will be adjusted based on the previous arterial glucose result. Patients in both groups will have their blood glucose adjusted according to arterial glucose values and a uniform protocol. Surgical and other anesthetic management is completed according to standard LT practices.

DISCUSSION

This study intends to investigate the effectiveness of CGM-based intraoperative glucose management and its impact on the prognosis of LT patients by comparing the GV, mean glucose values, and the incidence of hypo/hypoglycemic events guided by the above two glucose monitoring methods.

TRIAL REGISTRATION

This study is registered at www.chictr.org.cn on January 4, 2022, under the registration number ChiCTR2200055236.

Implementation of a Perioperative Glycemic Management Quality Improvement Pathway in Gynecologic Oncology Patients: A Single-cohort Interrupted Time-series Analysis

OBJECTIVE

We evaluated implementation and clinical outcomes of a perioperative glycemic management pathway in gynecologic oncology.

METHODS

Interrupted time-series analysis was used to compare process, balancing and outcome measures and clinical outcomes from 18 months preimplementation to 18 months postimplementation.

RESULTS

Compared with in the preimplementation period, the proportion of patients who underwent preoperative screening with glycated hemoglobin in the postimplementation period increased by 11.3% (95% confidence interval [CI], 5.0% to 17.7%; p=0.001). The proportion of patients with diabetes who had at least 1 blood glucose measurement after surgery increased by 15.3% (95% CI, -3.2% to 33.8%; p=0.10). There was no change in the proportion of patients who had any hyperglycemia or moderate or severe hyperglycemia. The median length of stay decreased by 0.42 days (95% CI, -0.91 to 0.07 days; p=0.09). There were major quality gaps in perioperative glycemic management that did not clearly improve after implementation of a multidisciplinary care pathway.

CONCLUSION

Optimal strategies for improvement of perioperative glycemic management are not yet known.

The Interdisciplinary Approach: Preventive and Therapeutic Strategies for Diabetic Foot Ulcers

The appropriate treatment of the common diabetic foot ulcers (DFUs) in diabetic patients demands enormous human, organizational and financial resources that are finite. Interdisciplinary teams of medical and surgical specialists, as well as allied health professionals, can help to reduce the consumption of these resources, optimize treatment, and prevent DFUs. They consist primarily of vascular surgeons, endocrinologists, and orthopedic foot and ankle surgeons and are closely supported when required by infectious diseases specialists, plastic surgeons, wound care specialist nurses, podiatrists, and orthotists. A timely interdisciplinary team review in each clinic session decreases the number of hospital visits for the oftentimes-handicapped diabetic patients significantly. The interdisciplinary team clinic setup has also been shown to reduce the risk of amputations, length of hospital staz and mortality rates.

A Retrospective Analysis Demonstrates That a Failure to Document Key Comorbid Diseases in the Anesthesia Preoperative Evaluation Associates With Increased Length of Stay and Mortality

BACKGROUND

The introduction of electronic health records (EHRs) has helped physicians access relevant medical information on their patients. However, the design of EHRs can make it hard for clinicians to easily find, review, and document all of the relevant data, leading to documentation that is not fully reflective of the complete history. We hypothesized that the incidence of undocumented key comorbid diseases (atrial fibrillation [afib], congestive heart failure [CHF], chronic obstructive pulmonary disease [COPD], diabetes, and chronic kidney disease [CKD]) in the anesthesia preoperative evaluation was associated with increased postoperative length of stay (LOS) and mortality.

METHODS

Charts of patients >18 years who received anesthesia in an inpatient facility were reviewed in this retrospective study. For each disease, a precise algorithm was developed to look for key structured data (medications, lab results, structured medical history, etc) in the EHR. Additionally, the checkboxes from the anesthesia preoperative evaluation were queried to determine the presence or absence of the documentation of the disease. Differences in mortality were modeled with logistic regression, and LOS was analyzed using linear regression.

RESULTS

A total of 91,011 cases met inclusion criteria (age 18-89 years; 52% women, 48% men; 70% admitted from home). Agreement between the algorithms and the preoperative note was >84% for all comorbidities other than chronic pain (63.5%). The algorithm-detected disease not documented by the anesthesia team in 34.5% of cases for chronic pain (vs 1.9% of cases where chronic pain was documented but not detected by the algorithm), 4.0% of cases for diabetes (vs 2.1%), 4.3% of cases for CHF (vs 0.7%), 4.3% of cases for COPD (vs 1.1%), 7.7% of cases for afib (vs 0.3%), and 10.8% of cases for CKD (vs 1.7%). To assess the association of missed documentation with outcomes, we compared patients where the disease was detected by the algorithm but not documented (A+/P-) with patients where the disease was documented (A+/P+). For all diseases except chronic pain, the missed documentation was associated with a longer LOS. For mortality, the discrepancy was associated with increased mortality for afib, while the differences were insignificant for the other diseases. For each missed disease, the odds of mortality increased 1.52 (95% confidence interval [CI], 1.42-1.63) and the LOS increased by approximately 11%, geometric mean ratio of 1.11 (95% CI, 1.10-1.12).

CONCLUSIONS

Anesthesia preoperative evaluations not infrequently fail to document disease for which there is evidence of disease in the EHR data. This missed documentation is associated with an increased LOS and mortality in perioperative patients.

Suggested Canadian Standards for Perioperative/Periprocedure Glycemic Management in Patients With Type 1 and Type 2 Diabetes

OBJECTIVES

The goal of this quality initiative was to develop consensus standards for glycemic management of patients with diabetes who undergo surgical procedures in Canada.

METHODS

A modified Delphi method was used to gather broad stakeholder input and arrive at a consensus for perioperative/periprocedure diabetes management.

RESULTS

Glycemic management standards were developed for the following categories: Organization of Care; Preoperative Assessment; Immediate Preoperative and Intraoperative; Postanesthesia Care Unit or Recovery Room; Postoperative Period; and Transition to Outpatient Care.

CONCLUSIONS

It is anticipated these standards will serve as a basis to develop clinical tools to support the recommendations.

Use of interrupted time series methods in the evaluation of health system quality improvement interventions: a methodological systematic review

BACKGROUND

When randomisation is not possible, interrupted time series (ITS) design has increasingly been advocated as a more robust design to evaluating health system quality improvement (QI) interventions given its ability to control for common biases in healthcare QI. However, there is a potential risk of producing misleading results when this rather robust design is not used appropriately. We performed a methodological systematic review of the literature to investigate the extent to which the use of ITS has followed best practice standards and recommendations in the evaluation of QI interventions.

METHODS

We searched multiple databases from inception to June 2018 to identify QI intervention studies that were evaluated using ITS. There was no restriction on date, language and participants. Data were synthesised narratively using appropriate descriptive statistics. The risk of bias for ITS studies was assessed using the Cochrane Effective Practice and Organisation of Care standard criteria. The systematic review protocol was registered in PROSPERO (registration number: CRD42018094427).

RESULTS

Of 4061 potential studies and 2028 unique records screened for inclusion, 120 eligible studies assessed eight QI strategies and were from 25 countries. Most studies were published since 2010 (86.7%), reported data using monthly interval (71.4%), used ITS without a control (81%) and modelled data using segmented regression (62.5%). Autocorrelation was considered in 55% of studies, seasonality in 20.8% and non-stationarity in 8.3%. Only 49.2% of studies specified the ITS impact model. The risk of bias was high or very high in 72.5% of included studies and did not change significantly over time.

CONCLUSIONS

The use of ITS in the evaluation of health system QI interventions has increased considerably over the past decade. However, variations in methodological considerations and reporting of ITS in QI remain a concern, warranting a need to develop and reinforce formal reporting guidelines to improve its application in the evaluation of health system QI interventions.

Institution of Monthly Anesthesia Quality Reports Does Not Reduce Postoperative Complications despite Improved Metric Compliance

While quality programs have been shown to improve provider compliance, few have demonstrated conclusive improvements in patient outcomes. We hypothesized that there would be increased metric compliance and decreased postoperative complications after initiation of an anesthesiology quality improvement program at our institution. We performed a retrospective study of all adult inpatients having anesthesia for a twelve-month period that spanned six months before and after program implementation. The primary outcome was the rate of complications in the post-implementation period. Secondary outcomes included the change in proportion of complications and compliance with quality metrics. We studied a total of 9620 adult inpatient cases, subdivided into pre- and post-implementation groups (4832 vs 4788.) After multivariate model adjustment, the rate of any complication (our primary outcome) was not significantly changed (32% to 31%; adjusted P = 0.410.) Of the individual complications, only wound infection (2.0% to 1.5%; adjusted P = 0.020) showed a statistically significant decrease. Statistically and clinically significant increases in compliance were seen for the BP-02 Avoiding Monitoring Gaps metric (81% to 93%, P < 0.001), both neuromuscular blockade metrics (NMB-01 76% to 91%, P < 0.001; NMB-02 95% to 97%, P = 0.006), both tidal volume metrics (PUL-01 84% to 93%, P < 0.001; PUL-02 30% to 45%, P < 0.001), and the TEMP-02 Core Temperature Measurement metric (88% to 94%, P < 0.001). Implementation of a comprehensive quality feedback program improved metric compliance but was not associated with a change in postoperative complications.

Perioperative Management of Elderly patients (PriME): recommendations from an Italian intersociety consensus

BACKGROUND

Surgical outcomes in geriatric patients may be complicated by factors such as multiple comorbidities, low functional performance, frailty, reduced homeostatic capacity, and cognitive impairment. An integrated multidisciplinary approach to management is, therefore, essential in this population, but at present, the use of such an approach is uncommon. The Perioperative Management of Elderly patients (PriME) project has been established to address this issue.

AIMS

To develop evidence-based recommendations for the integrated care of geriatric surgical patients.

METHODS

A 14-member Expert Task Force of surgeons, anesthetists, and geriatricians was established to develop evidence-based recommendations for the pre-, intra-, and postoperative care of hospitalized older patients (≥ 65 years) undergoing elective surgery. A modified Delphi approach was used to achieve consensus, and the strength of recommendations and quality of evidence was rated using the U.S. Preventative Services Task Force criteria.

RESULTS

A total of 81 recommendations were proposed, covering preoperative evaluation and care (30 items), intraoperative management (19 items), and postoperative care and discharge (32 items).

CONCLUSIONS

These recommendations should facilitate the multidisciplinary management of older surgical patients, integrating the expertise of the surgeon, the anesthetist, the geriatrician, and other specialists and health care professionals (where available) as needed. These roles may vary according to the phase and setting of care and the patient's conditions.

The Impact of an Intraoperative Clinical Decision Support Tool to Optimize Perioperative Glycemic Management

With the transition from Vanderbilt's Perioperative Information Management System (VPIMS) to Epic's Best Practice Advisory (BPA) framework, a replacement intraoperative glucose clinical decision support (CDS) system was designed. We examined changes in the frequency of intraoperative glucose monitoring, hyper- and hypoglycemia rates in the post-anesthesia care unit (PACU), to determine the impact of the changes on glucose management. Data were collected into three phases: 1) VPIMS CDS, 2) No CDS, and 3) BPA CDS. One-way ANOVA was conducted to test the significance of changes in the frequency of glucose monitoring and abnormal glucose across phases. Interrupted time series segmented analysis was performed to assess the autocorrelation and trend over times. A total of 3706 cases were analyzed. The monitoring rate fell from 84.5% in VPIMS CDS to 67.6% in No CDS (p < .001) and increased to 83.1% in BPA CDS (p < .001). The PACU hyperglycemia rate increased from VPIMS CDS to No CDS (5.2% to 10.4%, p < .001) and decreased from No CDS to BPA CDS (10.4% to 7.2%, p = 0.031). The segmented analysis demonstrated immediate changes in the intraoperative monitoring frequency (p < .001) and postoperative hyperglycemia rate (p = 0.002) with the replacement of CDS. The temporary removal of CDS was associated with a significant reduction in intraoperative glucose monitoring and increased hyperglycemia in the PACU. Implementation of the BPA CDS led to a significant improvement in the intraoperative glucose monitoring and glucose management in the PACU.

Considerations for Integration of Perioperative Electronic Health Records Across Institutions for Research and Quality Improvement: The Approach Taken by the Multicenter Perioperative Outcomes Group

Use of the electronic health record (EHR) has become a routine part of perioperative care in the United States. Secondary use of EHR data includes research, quality, and educational initiatives. Fundamental to secondary use is a framework to ensure fidelity, transparency, and completeness of the source data. In developing this framework, competing priorities must be considered as to which data sources are used and how data are organized and incorporated into a useable format. In assembling perioperative data from diverse institutions across the United States and Europe, the Multicenter Perioperative Outcomes Group (MPOG) has developed methods to support such a framework. This special article outlines how MPOG has approached considerations of data structure, validation, and accessibility to support multicenter integration of perioperative EHRs. In this multicenter practice registry, MPOG has developed processes to extract data from the perioperative EHR; transform data into a standardized format; and validate, deidentify, and transfer data to a secure central Coordinating Center database. Participating institutions may obtain access to this central database, governed by quality and research committees, to inform clinical practice and contribute to the scientific and clinical communities. Through a rigorous and standardized approach to ensure data integrity, MPOG enables data to be usable for quality improvement and advancing scientific knowledge. As of March 2019, our collaboration of 46 hospitals has accrued 10.7 million anesthesia records with associated perioperative EHR data across heterogeneous vendors. Facilitated by MPOG, each site retains access to a local repository containing all site-specific perioperative data, distinct from source EHRs and readily available for local research, quality, and educational initiatives. Through committee approval processes, investigators at participating sites may additionally access multicenter data for similar initiatives. Emerging from this work are 4 considerations that our group has prioritized to improve data quality: (1) data should be available at the local level before Coordinating Center transfer; (2) data should be rigorously validated against standardized metrics before use; (3) data should be curated into computable phenotypes that are easily accessible; and (4) data should be collected for both research and quality improvement purposes because these complementary goals bolster the strength of each endeavor.

Liraglutide for perioperative management of hyperglycaemia in cardiac surgery patients: a multicentre randomized superiority trial

AIMS

Most cardiac surgery patients, with or without diabetes, develop perioperative hyperglycaemia, for which intravenous insulin is the only therapeutic option. This is labour-intensive and carries a risk of hypoglycaemia. We hypothesized that preoperative administration of the glucagon-like peptide-1 receptor agonist liraglutide reduces the number of patients requiring insulin for glycaemic control during cardiac surgery.

MATERIALS AND METHODS

In this randomized, blinded, placebo-controlled, parallel-group, balanced (1:1), multicentre randomized, superiority trial, adult patients undergoing cardiac surgery in four Dutch tertiary hospitals were randomized to receive 0.6 mg subcutaneous liraglutide on the evening before surgery and 1.2 mg after induction of anaesthesia or matching placebo. Blood glucose was measured hourly and controlled using an insulin-bolus algorithm. The primary outcome was insulin administration for blood glucose >8.0 mmol/L in the operating theatre. Research pharmacists used centralized, stratified, variable-block, randomization software. Patients, care providers and study personnel were blinded to treatment allocation.

RESULTS

Between June 2017 and August 2018, 278 patients were randomized to liraglutide (139) or placebo (139). All patients receiving at least one study drug injection were included in the intention-to-treat analyses (129 in the liraglutide group, 132 in the placebo group). In the liraglutide group, 55 (43%) patients required additional insulin compared with 80 (61%) in the placebo group and absolute difference 18% (95% confidence interval 5.9-30.0, P = 0.003). Dose and number of insulin injections and mean blood glucose were all significantly lower in the liraglutide group. We observed no difference in the incidence of hypoglycaemia, nausea and vomiting, mortality or postoperative complications.

CONCLUSIONS

Preoperative liraglutide, compared with placebo, reduces insulin requirements while improving perioperative glycaemic control during cardiac surgery.

Development and Implementation of a Perioperative Blood Glucose Monitoring Protocol for Patients Undergoing Spinal Surgery

PURPOSE

Stress-induced hyperglycemia during the perioperative period is associated with adverse outcomes after spinal surgery, which increases both patient-related burden and hospital costs. This quality improvement project describes the development and implementation of a perioperative blood glucose monitoring protocol for patients undergoing spinal surgery.

DESIGN

An evidence-based perioperative blood glucose monitoring protocol was developed by a multidisciplinary committee of specialists in endocrinology and anesthesiology with utilization of the American Diabetes Association diabetes screening criteria.

METHODS

The protocol was implemented in the perioperative areas of a regional hospital in the Southeastern United States. The project sample included patients with and without a prior diagnosis of diabetes who met protocol inclusion criteria during a 3-month implementation period.

FINDINGS

Preoperative glycated hemoglobin (HbA1c) testing identified more than 54% of previously undiagnosed patients with levels consistent with either prediabetes or diabetes according to the American Diabetes Association criteria for diagnosis. Patients with diabetes and those without diabetes experienced a perioperative increase in blood glucose with levels remaining elevated above preoperative baseline through postoperative day 1.

CONCLUSIONS

A perioperative blood glucose monitoring protocol enables preoperative identification of patients with undiagnosed prediabetes and diabetes, allowing for optimization before elective surgery and establishment of appropriate postoperative follow-up care. In addition, a blood glucose monitoring protocol increases the detection of perioperative hyperglycemia and may lead to a reduction in postoperative complications after spinal surgery.

CYP2D6 Genotype-guided Metoprolol Therapy in Cardiac Surgery Patients: Rationale and Design of the Pharmacogenetic-guided Metoprolol Management for Postoperative Atrial Fibrillation in Cardiac Surgery (PREEMPTIVE) Pilot Study

OBJECTIVES

The Preemptive Pharmacogenetic-guided Metoprolol Management for Atrial Fibrillation in Cardiac Surgery (PREEMPTIVE) pilot trial aims to use existing institutional resources to develop a process for integrating CYP2D6 pharmacogenetic test results into the patient electronic health record, to develop an evidence-based clinical decision support tool to facilitate CYP2D6 genotype-guided metoprolol administration in the cardiac surgery setting, and to determine the impact of implementing this CYP2D6 genotype-guided integrated approach on the incidence of postoperative atrial fibrillation (AF), provider, and cost outcomes.

DESIGN

One-arm Bayesian adaptive design clinical trial.

SETTING

Single center, university hospital.

PARTICIPANTS

The authors will screen (including CYP2D6 genotype) up to 600 (264 ± 144 expected under the adaptive design) cardiac surgery patients, and enroll up to 200 (88 ± 48 expected) poor, intermediate, and ultrarapid CYP2D6 metabolizers over a period of 2 years at a tertiary academic center.

INTERVENTIONS

All consented and enrolled patients will receive the intervention of CYP2D6 genotype-guided metoprolol management based on CYP2D6 phenotype classified as a poor, intermediate, extensive (normal), or ultrarapid metabolizer.

MEASUREMENTS AND MAIN RESULTS

The primary outcome will be the incidence of postoperative AF. Secondary outcomes relating to rates of CYP2D6 genotype-guided prescription changes, costs, lengths of stay, and implementation metrics also will be investigated.

CONCLUSIONS

The PREEMPTIVE pilot study is the first perioperative pilot trial to provide essential information for the design of a future, large-scale trial comparing CYP2D6 genotype-guided metoprolol management with a nontailored strategy in terms of managing AF. In addition, secondary outcomes regarding implementation, clinical benefit, safety, and cost-effectiveness in patients undergoing cardiac surgery will be examined.

Early Intervention for Diabetes in Medical and Surgical Inpatients Decreases Hyperglycemia and Hospital-Acquired Infections: A Cluster Randomized Trial

OBJECTIVE

To investigate if early electronic identification and bedside management of inpatients with diabetes improves glycemic control in noncritical care.

RESEARCH DESIGN AND METHODS

We investigated a proactive or early intervention model of care (whereby an inpatient diabetes team electronically identified individuals with diabetes and aimed to provide bedside management within 24 h of admission) compared with usual care (a referral-based consultation service). We conducted a cluster randomized trial on eight wards, consisting of a 10-week baseline period (all clusters received usual care) followed by a 12-week active period (clusters randomized to early intervention or usual care). Outcomes were adverse glycemic days (AGDs) (patient-days with glucose <4 or >15 mmol/L [<72 or >270 mg/dL]) and adverse patient outcomes.

RESULTS

We included 1,002 consecutive adult inpatients with diabetes or new hyperglycemia. More patients received specialist diabetes management (92% vs. 15%, P < 0.001) and new insulin treatment (57% vs. 34%, P = 0.001) with early intervention. At the cluster level, incidence of AGDs decreased by 24% from 243 to 186 per 1,000 patient-days in the intervention arm (P < 0.001), with no change in the control arm. At the individual level, adjusted number of AGDs per person decreased from a mean 1.4 (SD 1.6) to 1.0 (0.9) days (-28% change [95% CI -45 to -11], P = 0.001) in the intervention arm but did not change in the control arm (1.8 [2.0] to 1.5 [1.8], -9% change [-25 to 6], P = 0.23). Early intervention reduced overt hyperglycemia (55% decrease in patient-days with mean glucose >15 mmol/L, P < 0.001) and hospital-acquired infections (odds ratio 0.20 [95% CI 0.07-0.58], P = 0.003).

CONCLUSIONS

Early identification and management of inpatients with diabetes decreased hyperglycemia and hospital-acquired infections.

Intraoperative hyperglycemia is independently associated with infectious complications after non-cardiac surgery

Background

Perioperative hyperglycemia and its associated increase in morbidity and mortality have been well studied in the critical care and cardiac surgery literature. However, there is little data regarding the impact of intraoperative hyperglycemia on post-operative infectious complications in non-cardiac surgery.

Methods

All National Surgery Quality Improvement Program patients undergoing general, vascular, and urological surgery at our tertiary care center were reviewed. After integrating intraoperative glucose measurements from our intraoperative electronic health record, we categorized patients as experiencing mild (8.3–11.0 mmol/L), moderate (11.1–16.6 mmol/L), and severe (≥ 16.7 mmol/L) intraoperative hyperglycemia. Using multiple logistic regression to adjust for patient comorbidities and surgical factors, we evaluated the association of hyperglycemia with the primary outcome of postoperative surgical site infection, pneumonia, urinary tract infection, or sepsis within 30 days.

Results

Of 13,954 patients reviewed, 3150 patients met inclusion criteria and had an intraoperative glucose measurement. 49% (n = 1531) of patients experienced hyperglycemia and 15% (n = 482) patients experienced an infectious complication. Patients with mild (adjusted odds ratio 1.30, 95% confidence interval [1.01 to 1.68], p-value = 0.04) and moderate hyperglycemia (adjusted odds ratio 1.57, 95% confidence interval [1.08–2.28], p-value = 0.02) had a statistically significant risk-adjusted increase in infectious complications. The model c-statistic was 0.72 [95% confidence interval 0.69–0.74].

Conclusions

This is one of the first studies to demonstrate an independent relationship between intraoperative hyperglycemia and postoperative infectious complications. Future studies are needed to evaluate a causal relationship and impact of treatment.

Electronic supplementary material

The online version of this article (10.1186/s12871-018-0546-0) contains supplementary material, which is available to authorized users.

Anesthesia information management: clinical decision support

PURPOSE OF REVIEW

Perioperative informatics tools continue to be developed at a rapid pace and offer clinicians the potential to greatly enhance clinical decision making. The goal of this review is to bring the reader updates on perioperative information management and discuss future research directions in the field.

RECENT FINDINGS

Clinical decision support tools become more timely, accurate, and, in some instances, have been shown to improve patient outcomes. When correctly implemented, they are critical tools for optimization of perioperative care.

SUMMARY

Perioperative informaticians continue to test new and innovative ways to enhance the delivery of anesthesia care, improving the safety and efficacy of perioperative management. Future work will continue to refine tools to ensure that perioperative informatics provides clinicians timely and accurate feedback, with demonstrable evidence that a decision support system improves patient outcomes.

Recent advances in perioperative glucose monitoring

PURPOSE OF REVIEW

There is ongoing controversy surrounding the use of glucose monitoring in the perioperative setting. It is an important aspect of patient care, but the best way to go about monitoring this parameter is still up for debate. This article will review previously established data and new developments in this field.

RECENT FINDINGS

Several different methods exist to measure blood glucose levels in the perioperative setting, including central laboratory devices, blood gas analyzers, and point-of-care devices. However, it has been recommended that point-of-care devices not be used on 'critically ill' patients, which throws into question the common use of these devices perioperatively. Recently, the Centers for Medicare and Medicaid placed a moratorium on this recommendation, and these devices continue to be a staple in the perioperative setting, but there are other methods of glucose monitoring that can be employed.

SUMMARY

The monitoring of blood glucose levels in the perioperative patient remains an important part of patient care; however, debate still exist on how best to reliably measure blood glucose levels in the most effective manner.

Impact of a Novel Multiparameter Decision Support System on Intraoperative Processes of Care and Postoperative Outcomes

Background

The authors hypothesized that a multiparameter intraoperative decision support system with real-time visualizations may improve processes of care and outcomes.

Methods

Electronic health record data were retrospectively compared over a 6-yr period across three groups: experimental cases, in which the decision support system was used for 75% or more of the case at sole discretion of the providers; parallel controls (system used 74% or less); and historical controls before system implementation. Inclusion criteria were adults under general anesthesia, advanced medical disease, case duration of 60 min or longer, and length of stay of two days or more. The process measures were avoidance of intraoperative hypotension, ventilator tidal volume greater than 10 ml/kg, and crystalloid administration (ml · kg–1 · h–1). The secondary outcome measures were myocardial injury, acute kidney injury, mortality, length of hospital stay, and encounter charges.

Results

A total of 26,769 patients were evaluated: 7,954 experimental cases, 10,933 parallel controls, and 7,882 historical controls. Comparing experimental cases to parallel controls with propensity score adjustment, the data demonstrated the following medians, interquartile ranges, and effect sizes: hypotension 1 (0 to 5) versus 1 (0 to 5) min, P &lt; 0.001, beta = –0.19; crystalloid administration 5.88 ml · kg–1 · h–1 (4.18 to 8.18) versus 6.17 (4.32 to 8.79), P &lt; 0.001, beta = –0.03; tidal volume greater than 10 ml/kg 28% versus 37%, P &lt; 0.001, adjusted odds ratio 0.65 (0.53 to 0.80); encounter charges $65,770 ($41,237 to $123,869) versus $69,373 ($42,101 to $132,817), P &lt; 0.001, beta = –0.003. The secondary clinical outcome measures were not significantly affected.

Conclusions

The use of an intraoperative decision support system was associated with improved process measures, but not postoperative clinical outcomes.

Perioperative Information Systems: Opportunities to Improve Delivery of Care and Clinical Outcomes in Cardiac and Vascular Surgery

A variety of existing perioperative informatics tools offer clinicians and researchers the opportunity to improve the delivery of care and clinical outcomes for patients undergoing cardiac and vascular surgery. Many of these tools can be used to improve the reliability of the care delivery process through the application of clinical decision support tools and/or quality improvement methodologies at a number of junctures. In this review, the authors will offer a concise overview of the existing perioperative informatics literature, with a focus on tools considered to be of utility in confronting the unique challenges inherent to cardiac and vascular surgery. The authors also highlight areas that they believe are of interest for future targeted inquiry.

Magic Mirror, on the Wall-Which Is the Right Study Design of Them All?-Part I

The assessment of a new or existing treatment or intervention typically answers 1 of 3 research-related questions: (1) "Can it work?" (efficacy); (2) "Does it work?" (effectiveness); and (3) "Is it worth it?" (efficiency or cost-effectiveness). There are a number of study designs that on a situational basis are appropriate to apply in conducting research. These study designs are classified as experimental, quasi-experimental, or observational, with observational studies being further divided into descriptive and analytic categories. This first of a 2-part statistical tutorial reviews these 3 salient research questions and describes a subset of the most common types of experimental and quasi-experimental study design. Attention is focused on the strengths and weaknesses of each study design to assist in choosing which is appropriate for a given study objective and hypothesis as well as the particular study setting and available resources and data. Specific studies and papers are highlighted as examples of a well-chosen, clearly stated, and properly executed study design type.