Evidence-Based Practice: Perioperative Procedure

Introduction

Preparation for surgery is often characterized by a variety of complications. Preparation of a list of things that must be done and those which must not be done is always necessary. Perioperative procedures are often aimed at improving outcome of an operation (Baeza, Fitzgerald & McGivern, 2008). Generally, they include pre-operational procedures, procedures performed during operation and post-operation procedures. Several activities are classified as perioperative procedures including anesthesia, glycemic control, and preparation of the surgical area (Clark, Currie & Hartog, 2007). However, this paper focuses on glycemic control as a perioperative procedure.

Perioperative procedure

Various researches have indicated that patients with good blood glucose control levels before and during surgery exhibit less likelihood of suffering postoperative. Postoperative include, though not limited pneumonia, infection of the wound, infection of the urinary tract, and system blood infection (Sepsis) (Clark, Currie & Hartog, 2007). Patients with diabetes have often been cited as having increased infection risk as compared to those who have stable sugar levels.

Control of blood sugar before, during and after surgical operations has therefore undergone considerable change in the level of importance as a perioperative procedure. As surgical operations increasingly become an acceptable form of treatment globally, many surgeons find an increased number of patients with unstable blood sugar levels under their care. Many surgical and anesthesia groups are therefore integrating this measure into perioperative evaluation and preparation. No universal protocols exist for perioperative glycemic control (Jacober & Sowers, 2009).

This is often attributed to an extensive treatment base present and individual customization needed in the reparation of treatment approach. Patients often exhibit differences in response to insulin administration as well as other hypoglycemic treatments (Shapiro, 2009). This is due to several factors that compound blood sugar levels including insulin resistance levels, general body metabolism, and stress factors suffered by the body. These differences reinforce the need to individually handle each case.

Anesthesia and surgery are known to induce both hormonal and inflammatory stress factors which have the likelihood of expounding risk complications associated with diabetic patients. Elevated levels of blood glucose result in unpleasant outcomes even to these patients not previously diagnosed with diabetes (Rehman & Mohammed, 2008). The relation between perioperative glucose control and perioperative outcomes can therefore not be ignored. However, a change in the implementation process is of necessity. There is a need that the implementation process to be altered into a more evidenced approach rather than a procedural obligation.

Often the approach employed may affect the outcome depending on prior evidence about individual patients. Before the day of surgery, little intervention is necessary. However, continuous emphasis is often placed on outpatient administration of regimens of insulin and diet. For patients already on hypoglycemics, no alterations are made before surgery. Patients are also advised to monitor pre and post-meal glucose variations. Patients are required to fast on the day of surgery. Depending on existing level of blood glucose, D5W or D5 1/2NS may be administered (Jacober & Sowers, 2009). However, it is often recommended that medical judgment override recommended procedures.

It is important to note that initially decisions on glycemic control were made by the chief surgeon and were primarily a measure of regulating blood glucose during surgical procedures (Rehman & Mohammed, 2008). This decision was purely on basis of regulation of blood glucose and failed to appreciate several issues that the process itself might present. This may range from use of inappropriate monitoring techniques for specific cases, adoption of procedures that result in counter-effects for individual patient cases and lack of adequate supportive grounds for the approach chosen.

The mode adopted is currently more procedural and meant to primarily balance blood glucose levels. Additionally, the procedure is driven by the need to maintain uniformity and hence limit the need for the hospitals to invest in varied techniques and processes (Shapiro, 2009). Additionally, it is argued that evidence-based practice requires more time on analysis of patient history and integrating scholarly decision-making into the same.

Clinical implications

Clinical implications of the approach employed include the availability of management patterns based on logical monitoring of blood glucose (Rehman & Mohammed, 2008). Medical indications and benefits of employed techniques as well as limitations are also a necessity. The hospital staff may also appropriately recognize innovative insulin delivery techniques and appliances to overcome obstacles to glycemic control. Additionally, this procedure shapes both pathophysiology and diagnostic criteria.

Cost efficiency

It must be mentioned that the current procedure being employed could be less costly and efficient both to the patient and the hospital if each case was individually handled based on evidence. Complications resulting from medical procedures often inflate medical costs needless to mention that some cases which may have otherwise required less costly monitoring techniques are subjected to expensive procedures (Rehman & Mohammed, 2008).

Basing judgments on evidence and integrating scholarly decision-making in the same ensures that appropriate measures are relevantly matched to suitable cases. While it has been previously that evidence-based practice in glycemic control increases the amount of time required and personnel and hence cost, this argument fails to appreciate the medical savings that the hospital is likely to have by reducing the rate of post-operation complications, making precise diagnoses and reducing chances of misdiagnosis.

Stakeholder participation

The success of evidence-based practice in glycemic control is however dependant on how well the stakeholders involved perform their roles. The stakeholders involved include the hospital management, the surgeons, anesthetists, and general practitioners. Patients also lay a key role in glycemic control and must therefore be treated as stakeholders. Incorporation of all stakeholders requires awareness campaigns that would see the stakeholders made aware of the benefits that evidence-based management is likely to bring into glycemic control. Patients need to be made aware of the crucial role they hold in terms of providing relevant and accurate information that can be effectively utilized in the determination of the active methodology.

The management has a responsibility of making creating a conducive environment for the implementation of the initiative. The surgeons, anesthetists, physicians and general practitioners are however the implementers of the process. They need to be made aware of the benefits of this initiative. They need to base glycemic control decisions on concrete evidence sourced from all aspects that provide information relevant to the patient and blood glucose levels both current and previous. This related to scholarly information available would ensure that this project is successful.

Barriers to procedural change and strategies of overcoming the barriers

Incorporating evidence-based practice into glycemic control is not without obstacles (Ciliska et al., 2005). Barriers to such changes are not only internal, but also external. However, major obstacles are presented by unwillingness of stakeholders to adopt the approach. As mentioned earlier, the management staff often tends to adopt methods they consider less costly at that particular time. It is difficult convincing the management of the perceived gains of altering a process they have previously invested heavily in (Ciliska et al., 2005).

Patients are also likely to give information that they want the practitioners to have rather than the information that the medical practitioners would want in order to aid the process. It is important to note that many studies indicate improved substantial improvement in healthcare management on basis of evidence-based care rather than medical expertise alone.

However, most practitioners are suffering lack of implementation knowledge, lack of skills about search and appraisal of evidence, increased time demands, constraints within the organizations e.g. unsupportive administration, misperceptions and lack of positive attitude, reverse expectations from patients, fear of undertaking unique approaches and the overwhelming information necessary in the incorporation of scholarly literature into evidence collected (Day, 2009). However, several measures are available to overcome the mentioned barriers in the incorporation of evidence-based practice into perioperative glycemic control (Gale & Schaffer, 2009).

The process of overcoming barriers to this initiative must begin with identification and analysis of the likely barriers to implementation (Hutchinson & Johnston, 2006). Surveys are important to identify the nurses/practitioners’ attitudes and beliefs about EBP usage in glycemic control. Awareness should be enhanced to strengthen their belief in EBP and information regarding possible benefits and milestones availed.

Case scenarios of successful care initiatives based on evidence-based management should be used to enlighten the physicians on the benefits and successes associated with EBP. Mis-perceptions associated with evidence-based practice should also be clarified to the practitioners. An example of a misconception is the thought amongst practitioners that EBP strategies are time-consuming while actual indications show that overall EBP practice results in shortened time for patient treatment due to reduced treatment time (Rycroft et al., 2005). Another example misconception that needs clarification is the assumption that it fails to take into consideration patient differences and medical expertise.

However, this is not the case as it takes into consideration all the best available evidence and insists on individual preferences as well as medical expertise as a major ingredient to decision-making about collected evidence. The practitioners should also be taught the basics of EBP in order to expound their implementation knowledge base with specific reference to glycemic control (Clark, Currie & Hartog, 2007). This is in recognition of the knowledge and skills necessary for the practitioners to effectively implement the initiative. This is possible through conferences and workshops both in-house and external.

Implementation of these measures is possible by bringing together all the stakeholders and setting a framework for implementation. Most importantly though, is ensuring that the support of the management is secured and the practitioners are well informed and hence their voluntary participation obtained. Incorporation of evidence-practice into glycemic control is a necessity would require that all stakeholders come together and realize the long-term gains associated with the same. Additionally, practitioners/physicians need to be engaged in constant training initiatives that endow them with the appropriate knowledge necessary in the implementation of EBP. Once the management and practitioners are on-board, it will be easy to bring in other stakeholders to participate in the process successfully.

References

Baeza, J., Fitzgerald, L. & McGivern, G. (2008). Change capacity: The route to service improvement in primary care. Quality in Primary Care, 16(2), p 401–407.

Ciliska, D. Et al. (2005). Using models and strategies for evidence-based practice. In Melnyk, B. M. Evidence-based practice in nursing and healthcare: A guide to best practice, 14(5), p. 185–219.

Clark, J. D., Currie, J. & Hartog, M. (2007). Management of diabetes in surgery: a survey of current practice by anesthetists. Diabetic Medical Journal, 9(3), p 271-274.

Day, C. (2009). Engaging the nursing workforce: An evidence-based tool kit. Nursing Administration Quarterly, 33(3), p 238–244.

Gale, B. & Schaffer, M. (2009). Organizational readiness for evidence-based practice. Journal of Nursing Administration, 39(2), p 91–97.

Hutchinson, A. M. & Johnston, L. (2006). Beyond the Barriers Scale: Commonly reported barriers to research use. Journal of Nursing Administration, 36(4), p 189–199.

Jacober, S. J. & Sowers, J. R. (2009). An Update on Perioperative Management of Diabetes. Arch Intern Med, 159(9), p 2405-2411.

Rehman, H. & Mohammed, K. (2008). Perioperative Management of Diabetic Patients. Current Surgery, 60(6): 607-611.

Rycroft, M. J.et al. (2005). An exploration of the factors that influence the implementation of evidence into practice. Journal of Clinical Nursing, 13(8), p 913–924.

Shapiro, S. E. (2009). Evidence-Based Practice for Advanced Practice Emergency Nurses: Using evidence as a basis for advanced practice in the ED. Advanced Emergency Nursing Journal, 29(4):331-338.