Case Studies: Specific Patient Groups
Patients with diabetes
The Perioperative team at the West Suffolk recognised that multidisciplinary team working with reorganisation of services would lead to better outcome (length of stay and less morbidity) of the elective surgical patient with diabetes.
To promote the reorganisation of services we appointed a dedicated diabetes surgical nurse. Amongst other tasks, she has communicated with the local GPs and most diabetic surgical patients are now referred to the surgeon with the most recent HbA1c, as well as concurrent medication.
All the patients are seen in pre-operative assessment (POA), and the pathway is designed to facilitate every patient with diabetes to be managed in the day surgery unit (DSU) when possible, as we recognise that DSU is the best place to perform elective surgery on patients with diabetes. This is because the risk of iatrogenic complications is minimised. In addition, when the patients are reviewed in PAU, they are all counselled to ensure that they know how to manage their diabetes medication to promote day of surgery admission (both for DSU and main theatres). In view of the recognised risk of hypoglycaemia , all patients in PAU are pre-prescribed rescue treatment for any inpatient hypoglycaemia.
In the rare occasions that we do need to use a variable rate intravenous insulin (VRIII) , the default fluid is 5% dextrose in 0.45% saline with premixed potassium.
All diabetic related medication incidents are reviewed, and lessons are constantly being learnt.
With this transformation of services, the majority of patients with diabetes are now being managed in DSU and the length of stay of our elective diabetic orthopaedic patients (mainly hip and knee replacements) is comparable to non-diabetics.
Referrals to a diabetic team at the Royal Bournemouth Hospital are made from a generic screening unit or nurse practitioners from specialist teams. If decisions are required regarding management of surgical pathway, patients are referred to an anaesthetic pre-assessment clinic. From 2010 until 2012, average length of stay of diabetic patients has reduced from 1.8 days higher than non-diabetic patients, to a similar level.
Type 2 diabetes mellitus is a growing health problem associated with significant adverse impact upon outcomes in the perioperative period. The latest NHS Digital Health Survey reveals that the prevalence of type 2 diabetes has more than doubled since 1994 to approximately 8% of the adult population and expectations are for this trend to continue. Of similar concern is the issue of the increasing number patients living with undiagnosed diabetes and prediabetes who present for scheduled surgery.
There is emerging evidence to support concerns surrounding the increased risk of major perioperative complications associated with stress hyperglycaemia in the perioperative period. Furthermore, patients with untreated chronic hyperglycaemia who subsequently develop hyperglycaemia in the perioperative period are more prone to suffer from cardiac complications than those with treated diabetes. Detection and careful clinical management of patients at risk of stress hyperglycaemia in advance of surgery holds significant theoretical potential to prevent avoidable perioperative complications.
The NCEPOD Highs and Low report (Dec 2018) has highlighted that satisfactory monitoring of established diabetic patients’ blood glucose levels in the perioperative period is an ongoing challenge. The historical lack of evidence of adverse outcomes associated with perioperative hyperglycaemia combined with evidence of harm from intravenous insulin infusions designed to maintain tight blood glucose control in the hospital setting has led to a less interventional approach to perioperative diabetic control.
We wished to determine the proportion of adult patients attending our preoperative clinic who presented a potential increased risk of perioperative stress hyperglycaemia (i.e. patients with known diabetes, undiagnosed diabetes and undiagnosed pre-diabetes respectively). During 2018, 12.5% of our preoperative clinic population presented with known diabetes, which is in keeping with 2018 PQIP report finding of 13%. To identify those with undiagnosed hyperglycaemia, we employed the validated University of Leicester Diabetes Risk Score screening tool in accordance with NICE guidance PH38 (to identify patients deemed at “high risk” of having or developing type 2 diabetes).
A total of 8151 patients were screened between March and December 2018 in our pre-operative clinic. 1198 (12.4 %) were found to be at “high risk” category for diabetes. 1049 of these patients accepted an offer of HBA1c testing. 7% of patients tested had an HbA1c in the diabetic range and 24% of patients had an HbA1c in the pre-diabetic range according to UK reference range. Patients diagnosed with new diabetes (at a rate of approximately 2 per week) are now postponed and stabilised prior to elective surgery. Blood glucose monitoring during the perioperative period is now recommended for all identified pre-diabetic and diabetic patients to identify the development of perioperative stress hyperglycaemia.
In summary, HbA1c testing of the highest risk category of screened patients suggests that approximately 20% of our adult population present to our preoperative clinic with either undiagnosed pre-diabetes or diabetes. Identification of such patients in the preoperative period is warranted to help prevent avoidable perioperative complications and provides an ideal opportunity to improve patients’ long term health prospects in addition to improving short term surgical outcomes.
After introducing the UK’s first specialist pre-assessment clinic for patients with diabetes on a surgical pathway, the average length of stay for inpatients with diabetes at the Royal Bournemouth hospital has reduced to a level consistent with non-diabetic patients.
Since a ‘Root Cause Analysis Prescription Error Pathway’ was implemented, there has been a significant reduction in prescription errors and the Royal Bournemouth Hospital is now the best performing trust within Wessex with regards to insulin management and reduction in medication errors.
The Perioperative Quality Improvement Programme (PQIP) recommend that all patients with diabetes should benefit from a care plan – developed in collaboration between healthcare professionals and the patient – that is activated on admission to hospital. Diabetes UK recommend that hospitals should have a multidisciplinary perioperative diabetes team in place.
Patients with anaemia
Project OPERA: Optimising PERioperative Anaemia in colorectal surgery patients in Belfast City Hospital
As part of a wider strategy to introduce formal Enhanced Recovery After Surgery (ERAS) pathway a large retrospective audit performed in 2018 identified that 45% of our elective colorectal patients were anaemic at the time of surgery. We know that this can have many consequences including increased post-operative complications and length of stay and the need for blood transfusion (which is also associated with poorer outcomes).
Our aim is to reduce the percentage of patients undergoing elective bowel resection for colorectal cancer with pre-operative haemoglobins less than 130g/dL from 45% to 25% by June 2019.
As these patients were on a red flag pathway time to surgery was short which meant we had to identify and treat iron deficiency anaemia (IDA) earlier in the patient’s treatment pathway.
We undertook a range of changes using a PDSA methodology including:
- Surgical, anaesthetic and nursing teams were educated regarding audit results.
- We agreed that bloods including full blood count and haematinics should be sent from endoscopy at time of identification of tumour (advancing diagnosis by at least 1 month).
- Surgeons agreed to add these blood tests to a new “endoscopy staging pack”.
- We liaised with colleagues in cancer services to promote our new staging pack and designed poster.
- Agreed with programme treatment unit new process to prioritise red flag referrals for IV iron.
- Our cancer tracker now emails ERAS nurse with new suspected CRC cases to enable all patients are followed up.
- ERAS nurse checks blood results on receipt of emails so prompt referral can be made.
- We have developed an updated evidence based algorithm for treating IDA.
At UHS we have an established perioperative medicine service which includes, CPET, surgery school and high risk shared decision making clinics. Whilst piloting a perioperative anaemia service for colorectal, urology, HPB, Upper GI and Maxfax patients at UHS, we identified that referrals from the surgical teams were often too late to allow optimum treatment time for IV iron. To avoid the dilemma of whether or not to delay surgery to treat anaemia, we looked at ways of identifying anaemic patients within our own service to avoid having to rely on surgical teams making direct referrals.
We started to check haemoglobin [Hb] levels of patients attending for a CPET. It was identified that many patients had not had a recent [Hb] check. We therefore used a Hemocue device to undertake ‘point of care’ [Hb] tests on all patients who did not have a recent [Hb] result available (within 7 days of CPET). If the Hemocue identified a [Hb] of <130 g/L in males and 120 g/L in females the CPET team requested a full panel of haematinics to assess the degree and underlying cause of anaemia. Request of the haematinics as a “bundle” of tests was also set up to automatically notify the anaemia team that the bloods had been sent. In this way the results could be looked at immediately and a plan for treatment activated without any further referrals needed.
What was the impact?
The impact of the introduction of the Hemocue in the CPET Lab and the automated referral system using the haematinics “bundle” enabled anaemic patients to be identified earlier in their surgical pathway. Early identification resulted in anaemic patients receiving iron 2-3 weeks prior to surgery, therefore maximising the effectiveness of the iron treatment. Prior to this intervention there were up to 10 missed opportunities for optimisation of anaemia per month. This has now reduced by 50%.
Barriers / Enablers/ Sustainability
The only barriers to the effectiveness of this service was when patients were referred late in their pathway to the CPET service. However with regular feedback and data sharing of outcomes with the surgical teams this is rarely a problem.
There is an ongoing cost associated with the loan of the Hemocue device and consumables. However this is offset by the cost of a serum [Hb] test which would have otherwise been done.
This intervention has proved to be effective in identifying anaemia earlier in the surgical pathway and is likely to be sustainable as it has minimal impact on the workload of the exercise physiologists conducting CPET.
A preoperative anaemia-screening programme for patients undergoing elective surgery has been established and integrated into patient preoperative assessment. The primary aim of the service is to reduce perioperative blood transfusions, and the associated costs and complications of allogeneic blood transfusions.
Initially targeting patients undergoing high blood use specialities such as orthopaedic surgery, the resulting reduction in transfusion rates, shorter hospital stays and reduced perioperative complications seen in these specialties, has paved the way to open referrals from all other speciality areas.
The service has evolved and expanded over 10 years and now takes referrals for patients undergoing all types of surgery, predominantly pre-operatively but also perioperatively. With the timely use of IV Iron many surgical patients who would have started their surgical journey anaemic, respond to treatment, and are undergoing surgery with normal blood counts. These patients are less likely to require blood transfusions and therefore the risks associated with this limited resource.
With increased use of other transfusion alternatives, such as perioperative cell salvage and education surrounding restrictive transfusion triggers, we are able to support our surgical teams to achieve lower transfusion rates and improved surgical outcomes.
Patients at risk of blood transfusion perioperatively are identified in the nurse-led preoperative assessment clinic, referral to a specialist anaemia nurse is made to assess suitable optimisation options, including timely intravenous iron replacement and advice to follow blood conservation techniques intra-operatively eg. Point of care testing and cell salvage.
Anaemia is common in cardiac surgical patients. The National ACTA audit from 12 Cardiac Centres in the UK and 19,0333 patients showed that 31% (range 23-45%) had anaemia. Controlling for Euroscore these patients had an independent association with Transfusion, increased mortality and increased length of hospital stay.1 With this in mind, and as a participating centre we developed an Anaemia Preassessment and Treatment pathway. Given that the commonest cause of anaemia in the Surgical Population is Iron Deficiency Anaemia (IDA)2, the algorithm only involves one test of Iron status. This is unlike other algorithms that involve Transferrin Saturation and Total Iron binding Capacity. From previous work looking at the cost effectiveness of all of these tests and whether these tests added any further information we have found that Ferritin is adequate in picking up patients who would benefit from Intravenous Iron Pre Surgery, particularly patients that are likely to have major blood loss or haemodilution.
The Anaemia algorithm is illustrated in slide 1. The preassessment nurses in Cardiac Surgery follow this and patients are asked to come in for Intravenous Iron, which is delivered as in the Cardiac Day Case Unit. Patients are made aware of the rationale behind IV Iron by a short presentation which is displayed outside the consulting rooms where they are seen by the surgeons as well as the Day Case and Inpatient wards. (see Powerpoint )We have developed a simple to use prescription for Total Dose Intravenous Iron Therapy. This particular iron is given over a short time period, requires minimal nursing intervention and only one visit for the patient to hospital. The Prescription is illustrated in slide 2. So far we have seen an increase in Haemoglobin over a 4-6 week period of between 100-200 g/L. Our local data is showing that these patients are requiring less and even no Packed Red Cell Transfusion during their hospital stay.
Iron deficiency anaemia is common in patients undergoing colorectal surgery and this can be easily missed considering the nature of the pathology. Hence in close co-ordination with our Transfusion Team, Consultant Haematologists, Consultant Colorectal Surgeons and the Pre-operative team involving our nurses and Consultant Anaesthetists we have created a care pathway that will benefit our patient cohort.
Anaesthetists and haematologists at the Royal Bournemouth Hospital have developed an algorithm to manage preoperative anaemia, to reduce perioperative blood transfusion. Anaemia is identified at the Anaesthetic Preoperative Assessment Clinic and the patients are then treated according to a flow chart.
Pro-active Care for Older people undergoing Surgery (POPS)
Established in 2004,the POPs multidisciplinary team is led by a consultant geriatrician and engages with the patient throughout the surgical pathway, from preoperative assessment through the surgical admission to discharge to the community.
The POPS service has reduced postoperative complications and length of stay as evidenced in a published pre- and post study conducted in elective orthopaedic patients and is now being replicated across other units in the UK (e.g., Nottingham, Reading, Addenbrookes, Sheffield)
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