Don’t Miss a Beat if Your Patient’s Too Sweet

Project Topic:

Hyperglycemia and glycemic management in the post-operative cardiothoracic surgical patient population

Hospital Unit:

2 Cohen Step Down Unit (SDU)
Cardiothoracic Intensive Care Unit (CTU)

CSI Participants:

• Katelyn Cozzolino, BSN, RN, CVRN
• Amy Lorenz, BSN, RN
• Rosanna Morrone, BSN, RN, CVRN
• Gabrielle Zinnar, BSN, RN, CCRN, CSC

Video Presentation

View this CSI team's project presentation video to earn CERPs.

Project Goals/Objectives:

1. Revise insulin drip policy
2. Attain a rate of 90% blood glucose results taken from point-of-care testing (POCT) by nursing staff (instead of arterial blood gas [ABG] values)
3. Decrease 2 Cohen SDU/CTU patients experiencing hyperglycemic events to <20%

Project Outcomes:

1. Revised insulin drip policy
2. Reduced use of ABGs to treat blood glucose levels within the first 24 hours post-op on an insulin drip 26.3%
3. Boosted use of POCT within the first 24 hour post-op to determine blood glucose levels to greater than 82%
4. Decreased patients experiencing hyperglycemic events in 2 Cohen SDU 13% and achieved a major reduction in hyperglycemic event rates in CTU

Project Overview:

At the inception of this project, 24% of patients in CTU and 20% of 2 Cohen SDU patients experienced hyperglycemic events during their hospital stay. These outcomes are higher than our facility’s goal of <20% hyperglycemia occurrence. Therefore, the goal of this project was to decrease hyperglycemic events and to improve glycemic management in our post-operative cardiothoracic surgical patient population.

Our CSI team kicked off the project by creating an online survey, distributing it to staff in both the 2 Cohen SDU and CTU to determine baseline staff knowledge regarding North Shore’s insulin drip policy and glycemic management. After collecting this information, the CSI team met with the lead CTU intensivist and the endocrine team to discuss findings, where we proposed insulin drip policy revisions.

Changes to our insulin infusion policy consisted of:

• Initiation of insulin drip at a blood glucose level of >150mg/dl
• After insulin drip is turned off, blood glucose monitoring will be performed every two hours until time of sliding scale administration, not when the order is written
• Insulin drip orders will be discontinued by day-shift providers during morning rounds

The insulin drip policy was approved by the multidisciplinary governing board and uploaded to our ICU policy manual in July 2021. Our CSI team also kicked off the education component of our project in July. We taught staff about the project and new insulin drip policy changes. In addition, we identified and educated unit champions to support implementation of the revised policy.

Next, we performed manual chart audits to determine pre-clinical and post-clinical data for analysis regarding the rate of hyperglycemic events in 2 Cohen SDU and CTU, as well as the use of arterial blood gas (ABG) vs. point-of-care testing (POCT) to determine blood glucose levels during the first 24 hours post-op on an insulin drip.

We discussed our project midpoint findings during September 2021, with data collection and staff education continuing through December 2021. Our CSI team presented our project outcomes — successful introduction of a new insulin drip policy, reductions in hyperglycemic events and ABG use, and increase in POCT compliance ― at an a CSI Academy Innovation Conference in March 2022.