Perioperative Glycemic Control Questionnaire Thank you for taking the time to complete this questionnaire.

Please circle the answer choice that best reflects your institutions customary practice. When appropriate, please write in your response. 1. Does your institution have established protocols for glycemic control? A. During preoperative screening and scheduling (prior to the day of surgery) 1. Yes 3. Being developed, target completion date? _______________ 2. No Name of Contact:___________________ Number_______________ B. During immediate preoperative (day of surgery) and intraoperative periods 1. Yes 3. Being developed, target completion date? _______________ 2. No Name of Contact:___________________ Number_______________ C. During postoperative period 1. Yes 3. Being developed, target completion date? _______________ 2. No Name of Contact:___________________ Number_______________ 2. Which patients are screened for hyperglycemia prior to the scheduling of surgery (ie, prior to the day of surgery)? A. All patients B. Known Diabetics C. Patients meeting the following criteria _____________________________________________________________________ ______________________ _____________________________________________________________________ ______________________ 3. What screening methods are used prior to the scheduling of surgery? A. Point of Care Blood Glucose B. HbA1C C. Point of Care Blood Glucose + HbA1C D. No screening methods are currently in use 4. Which patients are screened for hyperglycemia on the day of surgery? A. All patients B. Known Diabetics C. Patients meeting the following criteria _____________________________________________________________________ ____________________

_____________________________________________________________________ ____________________ 5. At your facility, are any efforts made to schedule elective surgery for diabetic patients at a particular time (ie, first case of the day)? If so, when? A. Yes: When? ________________________ B. No 6. Does your institution have a dedicated diabetic consulting service in charge of glycemic control for patients undergoing surgery? A. Yes B. No 7. If you answered yes to the previous question, who comprises the diabetic consulting service? Circle all that apply. A. Endocrinology B. Internal Medicine C. Family Medicine D. Nursing E. Pharmacy 8. Who is responsible for glycemic control during the immediate preoperative period (ie, on the day of surgery)? Circle all that apply. A. Anesthesia B. Family Medicine C. Internal Medicine D. Surgeons E. Dedicated diabetic care team 9. What role do the following services provide for perioperative diabetic care? A. Pharmacy: _____________________________________________________________________ _______ B. Surgery: _____________________________________________________________________ _________ C. Anesthesia : _____________________________________________________________________ _____ D. Endocrinology: _____________________________________________________________________ _ E. Internal Medicine: ___________________________________________________________________ F. Family practice: _____________________________________________________________________

10. Which most closely represents your institutions optimization parameters of the well-controlled diabetic? A. HgA1C < 6 & Point of Care Blood Glucose < 120 B. HgA1C < 7 & Point of Care Blood Glucose < 150 C. HgA1C < 8 & Point of Care Blood Glucose < 180 D. HgA1C < 9 & Point of Care Blood Glucose < 210 11. At your institution when is optimization of blood glucose most important in the patient undergoing surgery? A. Three months before surgery B. Immediately before surgery C. At the time of surgical incision D. Immediately after surgery E. Three months postoperative 12. What is the preferred route of administration of insulin at your institution during the perioperative period? A. Subcutaneous B. Intravenous Bolus C. Intravenous Continuous (drip) 13. What is the type of insulin that is preferred at your institution during the perioperative period? A. Short acting (regular insulin) B. Ultra Short acting (lispro, aspart, etc) C. There is no established preference 14. What most closely represents your institutions thresholds for HgA1C and blood glucose values in the immediate preoperative period that automatically results in the cancellation of an elective surgery? Circle all that apply. A. HgA1C > 10 E. Point of Care Blood Glucose > 240 B. HgA1C > 11 F. Point of Care Blood Glucose > 270 C. HgA1C > 12 G. Point of Care Blood Glucose > 300 D. HgA1C > 13 H. Point of Care Blood Glucose > 330 I. Other: __________________________________________________________________ J. There are no established thresholds, and decisions to cancel an elective surgery are made by the anesthesiologist and/or surgeon on a case-by-case basis. 15. In conjunction with the patients blood glucose value, which other factors are used to determine the dosage of insulin administered to your patient in the perioperative period? A. BMI

B. Total daily insulin use C. Other: ___________________________________________________________________ 16. How does your institution manage the perioperative workflow challenges presented by a diabetic patient that must be optimized on the day of surgery? ___________________________________________________________________________ __________________ ___________________________________________________________________________ __________________ ___________________________________________________________________________ __________________ ___________________________________________________________________________ __________________ 17. If a patient is receiving continuous insulin therapy (ie, insulin drip) for an outpatient surgery and the infusion is discontinued postoperatively, what are the criteria that must be met to discharge this patient home on the day of surgery? A. Total insulin requirement is below a set threshold. Threshold: ________________ B. Patient is able to tolerate an oral diet C. There are no criteria D. Patient must be admitted and can not be discharged right away

Name: ____________________________________________ __________________________ Institution: _______________________________________

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