THE USE OF INSULIN TO REDUCE SURGICAL SITE INFECTIONS (SSIS) CAPTAIN DAVID BRADLEY MAJ JASMINE HOGAN MAJ KYONG WINKLER

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Evan Cain
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1 THE USE OF INSULIN TO REDUCE SURGICAL SITE INFECTIONS (SSIS) CAPTAIN DAVID BRADLEY MAJ JASMINE HOGAN MAJ KYONG WINKLER

OVERVIEW AND SIGNIFICANCE Surgical Sites infections is the 2nd most reported HAI in the US accounting for 17% of all HAI 2009) (Center for Disease Control and Prevention, Reducing SSI is one of Joint

2 OVERVIEW AND SIGNIFICANCE Surgical Sites infections is the 2nd most reported HAI in the US accounting for 17% of all HAI 2009) (Center for Disease Control and Prevention, Reducing SSI is one of Joint Commission safety goals (NPSG, 2014) Complications from SSIs include the following: Increased morbidity/mortality Longer hospital stay Increased financial burden to family and hospital (Whitehouse et al., 2002; De Lissovoy, 2009) Diabetes is a major risk factor for SSIs (Lipshuts and Gropper, 2009)

3 PICO-T QUESTION In adult patients with type II diabetes, undergoing surgery, how does insulin infusion compared to glucose sliding scale, affect the reduction of surgical site infections (SSI) within 30 days after surgery?

Index to Nursing and Allied Health (CINAHL)

4 PICO-T CATEGORY AND DATABASE PICO-T question category Intervention Search engine / database utilized Cumulative Index to Nursing and Allied Health (CINAHL) Public/Publisher Medical Literature Analysis and Retrieval System Online (PubMed)

5 SEARCH STRATEGY Mesh Terms Boolean Limits Results Geriatric OR older adults Geriatric OR older adults AND orthopedics procedures Geriatric OR older adults AND orthopedic procedures AND insulin infusion pump AND sliding scale glucose OR English AND AND Clinical Trial, RCT, Controlled Clinical Trial, Meta-Analysis, last 5 years, English Clinical Trial, RCT, Controlled Clinical Trial, Meta-Analysis, last 5 years, English

6 LEVEL OF EVIDENCE/ QUALITY RATING Level of evidence rating Level II 3 RCTs Sample Size Level IV 6 Retrospective 2 Prospective Sample Size mil Quality High - 3 Medium - 6 Low - 2

7 EVIDENCE SYNTHESIS RANDOMIZED CONTROL TRIALS Citation Sample Size Location Findings Kang et al., 2009 Umpierrez et al., South Korea 211 USA No significant difference in glucose levels Insulin infusion reduce SSI Gandhi et al., USA No significant difference in mean glucose levels intraoperatively

8 EVIDENCE SYNTHESIS OF RETROSPECTIVE STUDIES Citation Sample Size Location Findings Renthal et al., USA Ma et al., China Ramos et al., USA Marchant et al., 2009 Ata et al., Corney et al., ,030,013 USA USA 92 USA Decrease in SSI with insulin infusion No significant difference in post op SSI Correlation between hyperglycemia & SSI Correlation between hyperglycemia & SSI Correlation between hyperglycemia & SSI No significant difference in post op mortality/morbidity

9 EVIDENCE SYNTHESIS OF PROSPECTIVE STUDIES Citation Sample Size Location Findings Hirashima et al., USA Insulin infusion reduce SSI Pili-Fioury et al., France No significant difference in SSI post-op hyperglycemia

10 Citation PICOT LOE/Qual IV Infusion Sliding Scale Design Corney et al., IV / Low Retro. correlational Hirashima et al., IV / Medium Prosp. Cohort Umpierrez et al., II / Medium RCT Gandhi et al., II / Medium RCT Kang et al., II / Medium RCT Renthal et al., IV / High Retro. correlational Ma et al., IV / Low Retro. correlational Ramos et al., IV / Medium Retro. correlational Marchant et al., IV / High Retro. correlational Ata et al., IV / High Retro. correlational Pili-Fioury et al., IV / Medium Prosp. correlational KEY: More infections Fewer infections No difference

11 APPLICATION FOR NURSING PRACTICE Consistency Elevated glucose levels increase risk of SSI Adherance to insulin administration protocol Staff Training Proper use of equipment Joint Commission NPSG Implement evidence-based practices to prevent SSIs

12 FUTURE RESEARCH Areas to explore Other areas of high adult concentration Orthopedics Neurology Higher level of research needed in larger healthcare organizations More RCTs conducted in larger tertiary hospitals Geriatric population focus

13 SUMMARY PICO-T Intervention PubMed and CINAHL Search Strategy Yielded 11 articles for synthesis Relevance, Design, Level & Quality 3-Level II and 8-Level IV Application to clinical practice

14 REFERENCES Ata, A., Lee, J., Bestle, S. L., Desemone, J., & Stain, S. C. (2010). Postoperative hyperglycemia and surgical site infection in general surgery patients. Archives of Surgery, 145(9), Retrieved from Center for Disease Control and Prevention (2009). Retrieved from Corney, S. M, Dukatz, T., Rosenblatt, S., Harrison, B., Murray, R., Sakharova, A., & Balasubramamiam, M. (2012). Comparison of insulin pump therapy (continuous subcutaneous insulin infusion) to alternative methods for perioperative glycemic management in patients with planned postoperative admissions. Journal of Diabetes Science and Technology, 6(1), Retrieved from De Lissovoy, G. (2009). Surgical site infection: Incidence and impact on hospital utilization and treatment costs. American Journal of Infection Control, 37, Gandhi, G. Y., Nuttall, G. A., Abel, M. D., Mullany, C. J., Schaff, H. V., O Brien, P. C.,... McMahon, M. M. (2007). Intensive intraoperative insulin therapy versus conventional glucose management during cardiac surgery. Annals of Internal Medicine, 146(4), doi: / Hirashima, F., Patel, R. B., Adams, J. E., Bertges, D. J., Callas, P. W., Steinthorsson, G., & McSorley, J. (2012). Use of a postoperative insulin protocol decreases wound infection in diabetics undergoing lower extremity bypass. Journal of Vascular Surgery, 56(2), doi: /j.jvs

REFERENCES (CONT.) Kang, H., Ahn, K. J., Choi, J. Y., Park, H. J., Park, S. J., & Lee, S. K. (2009). Efﬁcacy of insulin glargine in perioperative glucose control in type 2 diabetic patients.

15 REFERENCES (CONT.) Kang, H., Ahn, K. J., Choi, J. Y., Park, H. J., Park, S. J., & Lee, S. K. (2009). Efﬁcacy of insulin glargine in perioperative glucose control in type 2 diabetic patients. European Society of Anaesthesiology, 26, doi: /eja.0b013e32832a0bff Lipshuts, K. M., & Gropper, M. K. (2009). Perioperative glycemic control. Anesthiology, 110(2), Ma, D., Chen, C., Lu, Y., Ma, J., Yin, P., Xie, J., Yu, X. (2013). Short-term effects of continuous subcutaneous insulin infusion therapy in perioperative patients with diabetes mellitus. Diabetes Technology & Therapeutics, 15(12), doi: pdf/ /dia Marchant, M. H., Viens, N. A., Cook, C., Vail, T. P., & Bolognesi, M. P. (2009). The impact of glycemic control and diabetes mellitus on perioperative outcomes after total joint arthroplasty. The Journal of Bone and Joint Surgery, 91(7), doi: /JBJS.H Pili-Floury, L., Mitifiot, F., Penfornis, A., Boichut, N., Tripart, M., Christophe, J.,... Samain, E. (2008). Glycemic dysregulation in nondiabetic surgery. Diabetes & Metabolism, 35(1), doi: /jdiabet Ramos, M., Khalpey, Z., Lipsitz, S., Steinberg, J., Panizales, M. T., Zinner, M., & Rogers, S. O. (2008). Relationship of perioperative hyperglycemia and postoperative infections in patients who undergo general and vascular surgery. Annals of Surgery, 248(4), doi: /SLA.0b013e d1

16 REFERENCES (CONT.) Renthal, N., Roe, E., Adams-Huet, B., & Raskin, P. (2013). A novel glucose-insulin infusion maintains perioperative glycemic control through multiple transition of care. The Journal of Perioperative Practice, 23(10), Retrieved from The Joint Commission. (2014). National Patient Safety Goal. Retrieved from Umpierrez, G., Smiliey, D., Jacobs, S., Peng, L., Tempon, A., Mulligan, P.,... Rizzo, M. (2011). Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes undergoing general surgery. Diabetes Care, 34(2), doi: /dc Whitehouse, J.D., Friedman, N.D., Kirkland, K. B., Richardson, W.J., & Sexton, D. J. (2002). The impact of surgical-site infections following orthopedic surgery at a community hospital and a university hospital: Adverse quality of life, excess length of stay and extra cost. Infection Control and Hospital Epidemiology, 23(4), Retrieved from

9/23/09. What are the key components of preoperative, intraoperative, & postoperative care of diabetes management? Rebecca L. Sturges, M.D.

9/23/09. What are the key components of preoperative, intraoperative, & postoperative care of diabetes management? Rebecca L. Sturges, M.D. RMHS Perioperative Summit: Perioperative Diabetes Management Rebecca L. Sturges, M.D. Oct 6, 2009 Mrs. B was referred by her orthopedic surgeon to your preoperative clinic to discuss medical management