Compliance with surgical care improvement project blood glucose--a marker for euglycemia, but does it put our patients at risk?

To improve outcomes in open heart surgery (OHS) patients, the Surgical Care Improvement Project (SCIP) requires 6 am postoperative day (POD) 1 and 2 blood glucose (BG) to be ≤200mg/dL. This study examined risk factors for SCIP noncompliance when using an insulin infusion protocol (IIP) and evaluated this SCIP metric as a surrogate for glycemic control. The authors divided 99 consecutive OHS patients, all subjected to 1 uniform IIP, into 2 groups: Group 1-SCIP compliant (n=79) and Group 2-SCIP noncompliant (n=20). They determined mean BG for the first 48 postoperative hours, percent of total time with hyperglycemia (% time BG >200mg/dL) for each group, and assessed risk of SCIP noncompliance as relates to multiple risk factors including intensity of IIP application, and switching to subcutaneous (SQ) insulin prior to 6 am on POD 2. Group 1 had lower mean BG than Group 2 and percent of total time with hyperglycemia, P<0.0001. Multivariate analysis showed diabetes, obesity in nondiabetics, and switching to SQ insulin prior to 6 am on POD 2 to be risk factors for SCIP noncompliance. The 6 am BG values on POD 1 or POD 2 each correlated with average postoperative BG, and compliance with the SCIP BG metric was associated with virtually uniform BG ≤200mg/dL. IIP application was not significantly different between groups (P=0.2). Only patients who had been switched to SQ insulin prior to 6 am POD 2 were noncompliant at 6 am on POD 2. There were hypoglycemic events (BG <70mg/dL) in 15 of 99 patients (15%), 12 of whom (80%) were in Group 1. Noncompliance with this SCIP measure occurred more frequently in patients with diabetes or, if nondiabetic, in those patients with obesity. A trend toward increased insulin assessments in the SCIP noncompliant group suggests that 1 uniform IIP for all patients may not be effective. By not requiring the reporting of hypoglycemia, SCIP may inadvertently be exposing patients to harm.