Measure ID
GLU-03
Domain
Description

Percentage of patients with perioperative glucose > 200 mg/dL with administration of insulin or glucose recheck within 90 minutes of original glucose measurement.

Measure Type
Process
Threshold
90%
Rationale

Surgical and anesthetic stress increases hyperglycemia incidence in both diabetics and non-diabetics.3 Perioperative hyperglycemia is mediated by the release of proinflammatory cytokines (e.g., TNF-alpha and IL-6) and elevated concentrations of catecholamines, growth hormone, glucagon, and glucocorticoids.4 These mediators induce metabolic alterations in carbohydrate balance that alter peripheral glucose uptake and utilization, increase gluconeogenesis, depress glycogenesis, and induce glucose intolerance and insulin resistance.  Hyperglycemia can also be drug induced (administration of steroids).

Acute hyperglycemia in the perioperative period is known to increase the incidence of wound infections, overall mortality, length of stay, acute kidney injury, and delayed wound healing. 2,5,7, 8-12 Use of insulin to correct perioperative hyperglycemia decreases the risk of hospital complications and mortality in cardiac and general surgery patients.6, 12 The American Association of Clinical Endocrinologists and American Diabetes Association recommend a treatment threshold of 180 mg/dL in critically ill hospitalized patients and a preprandial blood glucose goal of 140 mg/dL in non-critically hospitalized ill patients.13 Patients undergoing anesthesia who are subject to tight glucose control are at greater risk of hypoglycemia as the effects of anesthesia can mask the symptoms of hypoglycemia and current methods of treatment and monitoring put patients at risk of overcorrection.1 A relatively high threshold glucose level (greater than 200 mg/dL) is used for this measure to alleviate concerns that patients undergoing general anesthetics are at risk of overtreatment and hypoglycemia.1 Blood glucose may be rechecked in one hour.

Measure Time Period
Inclusions
  • All patients with glucose level greater than 200 mg/dL
  • Patients with and without diagnosis of diabetes
Exclusions
  • ASA 5 and 6 cases
  • Cases with measure duration (Preop Start to PACU End) ≤ 30 minutes
  • Glucose measurements > 200 mg/dL within 90 minutes before measure end (see ‘Other Measure Build Details’ for more information)
  • Labor Epidurals including Obstetric non-operative procedures (CPT: 01958) & Cesarean Delivery Cases (determined by the Obstetric Anesthesia Type value codes value codes 1, 2, 3, 5, 6, 7)
  • Outpatient cases with Anesthesia Start to Anesthesia end time less than 4 hours long
  • Patients age < 12 years

*Cases where the ‘Measure End Time’ precedes ‘Measure Start Time’ will be excluded and marked 'invalid'

Success Criteria
  • Administration of insulin within 90 minutes (either IV or sub Q routes) or
  • Recheck of glucose level within 90 minutes
Other Measure Details
  • Evaluate the following conditions for each high glucose. If *none* of the conditions are true for a given high glucose, the case is marked as flagged
    1. Another glucose value was resulted within 90 minutes of the high glucose = pass
    2. An insulin administration was given within 90 minutes of the high glucose = pass
    3. An insulin infusion is active when the high glucose was resulted = pass (Note: If no end time is available for an insulin infusion, the ‘measure end time’ will be considered the insulin infusion end time.)
    4. Insulin SQ adjustment: Insulin SQ was administered within 120 minutes before high glucose value = pass 
  • If two blood glucose levels are documented in the same minute, the lower blood glucose will be considered for this measure
  • Insulin doses sent to MPOG outside the measure time period will not be included for evaluation.
Risk Adjustment

Not applicable

Provider Attribution

Preop Time Period (preop start through anesthesia start): The first provider signed into the case.

Intraop Time Period (anes start through anes end): The provider signed in at the first glucose recheck or first administration of insulin. If neither occurred, then the responsible provider is the one signed in 90 minutes after the high glucose measurement.

Postop Time Period (anesthesia end through PACU End): The last providers signed into the case.

MPOG Concept Used

 Insulin 

  • 10229 Insulin Aspart
  • 10230 Insulin Glargine
  • 10231 Insulin Novolin
  • 10232 Insulin NPH
  • 10233 Insulin Regular
  • 10659 Insulin- Unspecified
  • 10752 Insulin Lispro
  • 10788 Insulin Detemir

Glucose

  • 3361  POC- Glucose (Fingerstick)
  • 3362  POC- Glucose (Unspecified Source)
  • 3405  POC- Blood Gas- Glucose
  • 5003  Formal Lab-Glucose, Serum/Plasma
  • 5036  Formal Lab-Blood Gas,Glucose
  • 10796 Glucose Chew Tablet
  • 10797 Glucose Gel 40%
Case Report Return Columns
References
  1. Akhtar, Shamsuddin, Paul G. Barash, and Silvio E. Inzucchi. 2010. “Scientific Principles and Clinical Implications of Perioperative Glucose Regulation and Control.” Anesthesia and Analgesia 110 (2): 478–97.
  2. Bellusse, Gislaine Cristhina, Julio Cesar Ribeiro, Isabel Cristina Martins de Freitas, and Cristina Maria Galvão. 2019. “Effect of Perioperative Hyperglycemia on Surgical Site Infection in Abdominal Surgery: A Prospective Cohort Study.” American Journal of Infection Control, December. https://doi.org/10.1016/j.ajic.2019.11.009.
  3. Duggan, Elizabeth W., Karen Carlson, and Guillermo E. Umpierrez. 2017. “Perioperative Hyperglycemia Management: An Update.” Anesthesiology 126 (3): 547–60.
  4. Esposito, Katherine, Francesco Nappo, Raffaele Marfella, Giovanni Giugliano, Francesco Giugliano, Myriam Ciotola, Lisa Quagliaro, Antonio Ceriello, and Dario Giugliano. 2002. “Inflammatory Cytokine Concentrations Are Acutely Increased by Hyperglycemia in Humans: Role of Oxidative Stress.” Circulation 106 (16): 2067–72.
  5. Frisch, Anna, Prakash Chandra, Dawn Smiley, Limin Peng, Monica Rizzo, Chelsea Gatcliffe, Megan Hudson, et al. 2010. “Prevalence and Clinical Outcome of Hyperglycemia in the Perioperative Period in Noncardiac Surgery.” Diabetes Care 33 (8): 1783–88.
  6. Furnary, Anthony P., Guangqiang Gao, Gary L. Grunkemeier, Yingxing Wu, Kathryn J. Zerr, Stephen O. Bookin, H. Storm Floten, and Albert Starr. 2003. “Continuous Insulin Infusion Reduces Mortality in Patients with Diabetes Undergoing Coronary Artery Bypass Grafting.” The Journal of Thoracic and Cardiovascular Surgery 125 (5): 1007–21.
  7. Gandhi, Gunjan Y., Gregory A. Nuttall, Martin D. Abel, Charles J. Mullany, Hartzell V. Schaff, Brent A. Williams, Lisa M. Schrader, Robert A. Rizza, and M. Molly McMahon. 2005. “Intraoperative Hyperglycemia and Perioperative Outcomes in Cardiac Surgery Patients.” Mayo Clinic Proceedings. Mayo Clinic 80 (7): 862–66.
  8. Joshi, Girish P., Frances Chung, Mary Ann Vann, Shireen Ahmad, Tong J. Gan, Daniel T. Goulson, Douglas G. Merrill, Rebecca Twersky, and Society for Ambulatory Anesthesia. 2010. “Society for Ambulatory Anesthesia Consensus Statement on Perioperative Blood Glucose Management in Diabetic Patients Undergoing Ambulatory Surgery.” Anesthesia and Analgesia 111 (6): 1378–87.
  9. Kotagal, Meera, Rebecca G. Symons, Irl B. Hirsch, Guillermo E. Umpierrez, E. Patchen Dellinger, Ellen T. Farrokhi, David R. Flum, and SCOAP-CERTAIN Collaborative. 2015. “Perioperative Hyperglycemia and Risk of Adverse Events among Patients with and without Diabetes.” Annals of Surgery 261 (1): 97–103.
  10. Kwon, Steve, Rachel Thompson, Patchen Dellinger, David Yanez, Ellen Farrohki, and David Flum. 2013. “Importance of Perioperative Glycemic Control in General Surgery: A Report from the Surgical Care and Outcomes Assessment Program.” Annals of Surgery 257 (1): 8–14.
  11. Mendez, Carlos E., Paul J. Der Mesropian, Roy O. Mathew, and Barbara Slawski. 2016. “Hyperglycemia and Acute Kidney Injury During the Perioperative Period.” Current Diabetes Reports 16 (1): 10.
  12. Moghissi, Etie S., Mary T. Korytkowski, Monica DiNardo, Daniel Einhorn, Richard Hellman, Irl B. Hirsch, Silvio E. Inzucchi, et al. 2009. “American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on Inpatient Glycemic Control.” Diabetes Care 32 (6): 1119–31.
  13. Pasquel FJ, Gianchandani R, Rubin DJ, et al. Efficacy of sitagliptin for the hospital management of general medicine and surgery patients with type 2 diabetes (Sita-Hospital): a multicentre, prospective, open-label, non-inferiority randomised trial. The lancetDiabetes & endocrinology. 2017;5(2):125-133.
  14. Ramos, Margarita, Zain Khalpey, Stuart Lipsitz, Jill Steinberg, Maria Theresa Panizales, Michael Zinner, and Selwyn O. Rogers. 2008. “Relationship of Perioperative Hyperglycemia and Postoperative Infections in Patients Who Undergo General and Vascular Surgery.” Annals of Surgery 248 (4): 585–91.
  15. Sheehy AM, Gabbay RA. An overview of preoperative glucose evaluation, management, and perioperative impact. J Diabetes Sci Technol. 2009 Nov 1;3(6):1261-9. doi: 10.1177/193229680900300605. PMID: 20144379; PMCID: PMC2787025.
  16. Umpierrez, Guillermo E., Scott D. Isaacs, Niloofar Bazargan, Xiangdong You, Leonard M. Thaler, and Abbas E. Kitabchi. 2002. “Hyperglycemia: An Independent Marker of in-Hospital Mortality in Patients with Undiagnosed Diabetes.” The Journal of Clinical Endocrinology and Metabolism 87 (3): 978–82.
  17. Umpierrez GE, Hellman R, Korytkowski MT, et al. Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline. The Journal of clinical endocrinology and metabolism. 2012;97(1):16-38.
Measure Authors
 Measure Author  Institution

 Brooke Szmanski-Bogart, RN

 University of Michigan

 Genevieve Bell

 University of Michigan

 Nirav Shah, MD

 University of Michigan

 MPOG Quality Committee

 
Measure Reviewer(s)
Next Review: 2023
 Date Reviewed  Reviewer  Institution  Summary  QC Vote
5/22/2023 Patrick Henson, MD Vanderbilt

Update the threshold for GLU-01, GLU-03, and GLU-05

to 180mg/dL, and develop new recheck measure

Revise

 

Version
Date Published: 09/2020
 Date  Criteria  Revision
 02/07/2023  Exclusion  Cases with measure duration ≤30 minutes excluded & cesarean delivery hysterectomies no longer excluded.
 10/28/2022  Success  If subcutaneous insulin was administered within 120 minutes before the high glucose result, value passes.
 03/24/2021  Exclusion  Modified to use Obstetric Anesthesia Type phenotype