Diabetes is the seventh leading cause of death in the United States. While it’s a common condition among patients presenting for elective surgery, it often predicts poor postsurgical outcomes. As the prevalence of diabetes continues to increase, and the global cost to treat and prevent diabetes complications is expected to exceed $490 billion in the next fifteen years, optimal screening, management and timing of elective surgery for this group of patients has become increasingly important and remains a population health challenge – a challenge Duke is meeting head-on.
After Duke Anesthesiology’s successful launch of the Preoperative Anemia Clinic (PAC) in September of 2014, serving as a multidisciplinary anemia management program to improve surgical outcomes for patients with chronic anemia, the department’s Perioperative Enhancement Team (POET) is taking yet another step toward redefining their role in perioperative medicine. This time, the team is targeting patients with uncontrolled diabetes scheduled to have spine surgery. On April 7, POET launched the Preoperative Diabetes Management Program and expanded the Preoperative Anemia Clinic for patients seen in the Duke Spine Center. It’s a collaborative effort between anesthesiologists, surgeons, endocrinologists and internal medicine with one common goal – improving glucose control before surgery to enhance the outcomes of Duke spine patients.
“This group of patients is of particular interest because when glucose is not controlled there is an increased risk for postoperative infection,” says anesthesiologist, Dr. Erin Manning. “These patients typically have substantial incisions and hardware placed inside their bodies which put them at higher risk of infections to begin with; combine that with poor glucose control and they don’t always heal well.”
“It’s crucially important that our patients are well prepared for the stress of surgery,” adds spine surgeon, Dr. Sergio Mendoza-Lattes. “It’s more than just surgical skills. This program is a way of getting patients safely through the experience with a good outcome.”
POET is the Department of Anesthesiology’s way to address the new reality in health care of managing risk in a volume-to-value transition. With the same principle that underscored the launch of the anemia clinic, POET wanted to expand to other sites of service to include the Duke Spine Center. “Our efforts are ways for the department to be more directly and proactively involved in the upstream identification of patients who would otherwise be high-risk – active participation in the management of modifiable risk factors so they no longer pose a threat to an adverse outcome downstream,” says Dr. Sol Aronson, anesthesiologist and medical director of POET who oversees its 54 projects.
The Preoperative Diabetes Management Program was developed for nearly ten months before its official launch with the involvement of about three dozen medical experts. “Part of the reason it took so long with what looks on the surface to be a pretty simple idea is because all team members had to be touched, connected and integrated into this new work stream and new process,” adds Dr. Aronson. “It’s quite methodical and there is a lot of necessary detail to ensure this program runs smoothly and effectively. The hope and expectation is by optimizing these modifiable risk factors before patients come to surgery, then the risk associated with them during surgery will be mitigated and outcomes will be improved.”
To make that happen, the team’s first tactic is to identify patients who are at risk of poor glycemic control. This alone requires multiple steps (see workflow diagrams below): once a patient is determined to be a surgical candidate at Duke, a nurse will review their chart to check for diabetes and A1C levels. If their most recent A1C test was performed in the last three months and is over 7.5, they are referred to a preoperative diabetes clinic with the expectation that they would go into surgery with a less likely chance of having an adverse outcome, including infection and poor wound healing (both of which are related to increased lengths of hospital stays and an increased expense to manage). According to Dr. Aronson, this alternative preoperative pathway leads patients into some significant lifestyle and perhaps medication modifications which could take between four and eight weeks to prepare themselves for surgery.
Endocrinologist, Dr. Tracy Setji, is the medical director for Duke’s inpatient endocrine consultation service. She notes that while four to eight weeks may sound like a delay, this program is actually an opportunity to optimize patient care in the fastest way possible. Dr. Setji helped develop protocol for both the screening criteria (A1C levels – the marker for glycemic control) and the identification of high-risk patients. She worked with POET to develop both the inpatient and outpatient protocols.
According to Dr. Setji, the protocol within this new program is also designed to capture the large number of patients with undiagnosed diabetes, which is just over eight million people, according to the latest research from the Centers for Disease Control and Prevention. Patients who are unaware of their diabetes have an even higher risk of perioperative mortality compared to patients who are aware of their condition. “In the past, there hasn’t been as much attention paid to glycemic control during hospitalizations or in the perioperative period, but over time, we’ve seen the associations of poor glycemic control and less optimal outcomes. Trying to target glucoses as a tangible way to improve outcomes is becoming an increasing recognized target,” she says.
Anesthesiology, in general, is heading into the field of perioperative medicine which is exciting for Dr. Manning because she says it provides a way for anesthesiologists to be involved with surgical and other medical colleagues to help patients overall, not just inside the operating room. In Dr. Manning’s role, she is helping to change the way patients’ glucose is managed in the OR. Working with endocrinology, anesthesiology developed a protocol that focuses on how they monitor glucose based on preoperative levels, ultimately changing interoperative management.
“It’s like air traffic control. We won’t land planes on the runway until we know all the wheels are down,” says Dr. Aronson. “In the past, we weren’t meticulously checking to make sure the wheels were down before we told the plane it was okay to land. Now, we’re proactively making certain that this is the case. Therefore, the need for communication becomes a significant part of this equation. And, the need for great air traffic control becomes quite obvious, quite quickly.”
According to Dr. Susan Spratt, endocrinologist and director of diabetes services for the Duke University Health System, 25 percent of Americans over the age of 65 have diabetes. The Duke Spine Center has about 1,200 spine cases each year – a large percentage of those patients are considered older Americans. Dr. Manning believes this new diabetes management program has the potential to help a significant number of Duke spine patients.
“Spine surgery is a team sport and we need all the right players,” adds Dr. Mendoza-Lattes. “It’s an endocrinologist’s dream that surgeons want to tackle this problem before surgery,” says Dr. Spratt. She built the order set that providers and the health system’s nursing staff use to tee-up orders to access glucose control and refer patients to Duke’s endocrinology clinic. “That’s one of the unique parts of this program. Often times, we’re called in late, after surgery, when patients’ blood sugars are high and they want to be discharged. Or, worse case scenario, they come back with an infection. So, we are thrilled that we are able to be proactive in this endeavor instead of reactive.”
The collaboration at the Duke Spine Center extends beyond diabetes. It will also impact patients with chronic anemia. According to Dr. Manning, spine patients are a good population to work with Duke’s Preoperative Anemia Clinic because there can be significant blood loss in the larger spine surgeries. The goal of the “anemia arm” is to have the patients optimized regarding hemoglobin levels with the expected outcome of giving them fewer blood transfusions in the OR and after surgery.
With the point of care testing already in place, the launch of these programs at the Duke Spine Center means patients now have expedited access to the necessary expertise to handle these specific health issues quickly and in advance of operations. So, what does the future hold for POET? Pain and nutrition are next in line in what the team hopes to be a series of other clinics and patient populations undergoing specific surgical procedures who can benefit from having their preoperative risk of anemia and diabetes identified and managed, according to Dr. Aronson. “It’s very rewarding and particularly, a year into the PAC, we can look back at our efforts and see the positive impact we’ve had on our patients. I’m very proud of everyone on this team.”
“We’re all very enthused about these programs and we hope to contribute and make them grow. At the end of the day, it’s not just the skill of the surgeons; it’s the whole team that contributes to the results and to the safety of the procedures,” says Dr. Mendoza-Lattes. “This is key – the Duke difference is a team approach.”
View the complete Duke Spine Center preoperative anemia workflow diagram and the diabetes management collaboration workflow diagram.