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A Multidisciplinary Approach

Robert Kramer, MD; Robert Groom, MS, CCP; Denise Weldner, BSN, RN; Paulette Gallant, MSN, RN; Barb Heyl, PA; Ryan Knapp, MS, MD; Anna Arnold, MPH

Arch Surg. 2008;143(5):451-456.

Objective  To demonstrate the multidisciplinary interactions and tools required to effect changes in the processes of care to achieve tight glycemic control (TGC) and reduce deep sternal wound infection (DSWI) rates in patients undergoing cardiac surgery.

Design  A retrospective cohort analysis comparing the rate of DSWI before and after implementing a multidisciplinary TGC initiative.

Setting  A cardiac surgical program in a tertiary care community hospital in New England.

Patients  A total of 3065 consecutive adult patients undergoing cardiac surgery who were operated on between January 1, 2004, and December 31, 2006.

Interventions  Evidence demonstrating the relationship between hyperglycemia and DSWI was presented to the multidisciplinary group caring for patients undergoing cardiac surgery. In addition, special emphasis was placed on nursing feedback and in-service training. A cumbersome glycemic management text protocol was replaced with a novel color-coded bedside tool (nomogram) to guide the bedside management of hyperglycemia. Subsequently, an algorithm for the transition to a home regimen was developed, which further improved standardization of care and ease of management.

Main Outcome Measures  Hourly blood glucose level monitoring and the incidence of DSWI.

Results  Eighteen months after the new program was initiated, the DSWI rate decreased by more than 60% from 2.6% to 1.0%, when compared with the preceding 18 months (P < .001).

Conclusion  A TGC program using a novel tool in a multidisciplinary setting was successfully and safely established, resulting in sustained improvement in the DSWI rate.

Author Affiliations: Division of Cardiothoracic Surgery, Maine Medical Center, Portland (Dr Kramer, Mr Groom, and Mss Weldner, Gallant, and Heyl); and the Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire (Mr Groom, Dr Knapp, and Ms Arnold).

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