Evaluating the Utilization of a Perioperative Hyperglycemic Protocol: A Quality Improvement Project.

PURPOSE: The purpose of this project to evaluate adherence to the perioperative hyperglycemic protocol among Certified Registered Nurse Anesthetists (CRNAs) at a large academic hospital. A secondary objective of this project is CRNAs' perceptions of barriers to point-of-care (POC) testing and the protocol. DESIGN: A quality improvement project. METHODS: Using Donabedian's conceptual framework, a Phase 1 retrospective chart analysis of 297 patients with diabetes undergoing noncardiac surgery before and after implementing POC testing for intraoperative glucose control was performed. Only patients with preoperative BG ≥ 180 mg/dL were included in this phase of the project, which involved a comparison of the protocol utilization before and after implementation of POC testing. Phase 2 included an assessment of CRNA's perceptions of the protocol. FINDINGS: The final sample included 91 (37 preimplementation; 54 postimplementation) participants. There were no significant demographic differences between the groups. Overall, 52.7% of patients had intraoperative glucose checks, and only 16.5% received insulin. Preoperative BG levels decreased 11.4-points, and postoperative BG levels increased 20.4 points when comparing pre- and postimplementation groups. However, there were significant differences in postoperative glucose levels, pre- and postimplementation. The survey showed that the majority (65.5%) of CRNAs identified difficulty locating the protocol as the primary barrier to utilization. CONCLUSIONS: Although all patients included in this project qualified for an intraoperative glucose check, findings revealed that only half of the patients had a glucose check and less than one fifth of the patients received insulin treatment, indicating poor adherence to the protocol. Thus, while implementing protocols is essential, utilization and adherence to the protocol are critical to improving patient outcomes. Recommendations for continued improvement include increasing protocol accessibility, staff training, compliance monitoring, and a more simple protocol structure.