Pharmacist-Led Program Helps Manage Blood Sugar After Surgery
With commentary by study co-author Karen Mularski, MD, a hospitalist at Kaiser Permanente Northwest, Portland.
When patients with diabetes undergo surgery, keeping an eye on their blood sugar during and after the procedure is crucial to keep them healthy, experts know. Better blood sugar control is linked with better results from the surgery, lower readmission rates to the hospital and fewer complications.
Now, Oregon researchers report that implementing a blood glucose control program with a team led by specially-trained pharmacists produces good results.
"What we found was, the blood sugar was much better controlled after implementation of the team," says Karen Mularski, MD, a study co-author and hospitalist at Kaiser Permanente Northwest, Portland.
While awareness of the need to monitor blood sugar in surgical patients is high, she says, it isn't always paid the attention it needs. "Doctors have so much to deal with, blood sugars can fall to the bottom of the list," she says. In the new program, keeping track of patient blood sugars was the only task for the pharmacists involved in the program. The pharmacists followed a strict protocol about blood sugar control. They determined the dose and regimen of insulin needed. If they had questions, they consulted with doctors overseeing the program, Dr. Mularski says.
The study is published in September/October 2015 print editition of The American Journal of Pharmacy Benefits.
The patients in the study were not critically ill. Their surgeries included such procedures as thyroid operations, appendectomies, hip replacement and hysterectomies.
The researchers compared the outcomes of about 4,800 patients during the first year of their two-year study and another 5,400 during the second year to about 1,200 patients hospitalized in 2008, the year before the two-year program started.
After the second year, those in the program were more than two times as likely as the pre-program patients to have well-controlled blood sugar the day after surgery. After the second year, those in the program were about 69 percent less likely to have low blood sugar, another danger, in the three days after surgery.
At the two-year mark, those in the program were also 33 percent less likely to be readmitted to the hospital for any reason three months after surgery and 28 percent less likely to need the ER three months afterdischarge.
Good control was defined as having all, or all but one, glucose value between 70 and 180 mg/dL in the first day after admission to the post-anesthesia care unit. Low blood sugar was defined as tests that were less than 70mg/dL in the three days after surgery.
Pharmacists and personalized care
The pharmacists were on duty 10 hours a day, seven days a week. They met individually with most patients to get a history and explain the program. "It's a different model that patients aren't used to," Dr. Mularski says. "They got a lot of expert, personalized care. Ultimately patients were really appreciative."
The pharmacists also explained to some patients why they were on insulin in the hospital when they were on oral diabetes medicines at home. "Most were on oral medicines [before being hospitalized]," Dr. Mularski says. However, it's typical to switch to insulin during surgery for better control, she says.
The program's goal, to improve outcomes by focusing on blood sugar controls, is a good one, says Minisha Sood, MD, director of inpatient diabetes at Lenox Hill Hospital, New York. She reviewed the findings. "This study shows a consistent team of people following a protocol can have a tremendous positive effect on glucose control before and after surgery," she says.
While this study involved pharmacists overseeing follow-up care related to blood sugar control, Dr. Sood says the results may have been the same with another health care provider dedicated to the effort. She speculates that a team of doctors and pharmacists would be even more ideal, providing ''that extra level of knowledge, training and experience."
Another expert, Raisa Telis, PharmD, inpatient pharmacist at Lenox Hill Hospital, says that "It's very important to have a permanent member of the team, whether pharmacist, [other] health care practitioners, someone who has knowledge of the patient."
Programs such as the Kaiser one are not common, Dr. Mularski says. Practices for monitoring blood sugar do vary from hospital to hospital, Dr. Sood says. Patients can advocate for themselves. She suggests the patient follow this script when admitted: "I have type 2 diabetes and these are my medications. I want to make sure my blood sugar is being managed appropriately before and after surgery. Is there a team in place? If not, can I speak to someone on my health care team [about it]?''