Perioperative Care of Patients with Diabetes

Collaborating to improve care for patients with diabetes

The Centre for Perioperative Care, working in partnership with Diabetes UK, is currently working on updating existing guidance for the care of the surgical patient with diabetes that will encompass the whole perioperative pathway

The Centre for Perioperative Care, working in partnership with Diabetes UK, is currently working on updating existing guidance for the care of the surgical patient with diabetes that will encompass the whole perioperative pathway. The impetus for the collaboration has arisen from the recommendations of the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report into the management of patients with diabetes undergoing surgery, Perioperative Diabetes: Highs and Lows.

Who is involved?

A working group has been convened that brings together experts from a variety of disciplines, with CPOC having appointed Prof Gerry Rayman and Dr Nicholas Levy as joint clinical leads to oversee the guideline’s development.

Prof Gerry Rayman

Prof Gerry Rayman is a consultant physician at the Diabetes and Endocrine Centre and the Diabetes Research Unit at Ipswich Hospital, as well as an honorary professor at University of East Anglia, visiting professor at the University of Suffolk, associate lecturer at Cambridge University, Diabetes UK’s clinical lead for inpatient care and the Getting It Right First Time (GIRFT) joint clinical lead for diabetes. He also devised the national diabetes inpatient audit (NaDIA) programme. This annual quality improvement project has repeatedly demonstrated that harm to inpatients with diabetes predominantly arises from hospital acquired hypoglycaemia, hospital acquired DKA, and  medication errors.  One of the main aims of the guideline authors is to reduce the rate of these preventable harms.

Dr Nicholas Levy

Dr Nicholas Levy is a consultant anaesthetist at West Suffolk Hospital and has had a keen interest in improving the perioperative management of surgical patients with diabetes for many years. He has contributed to all the previous major UK guidelines for the management of these patients and led the group that proposed that NCEPOD should conduct the aforementioned confidential enquiry. Like many anaesthetists he is also concerned that current guidance precludes the use of the continuous subcutaneous insulin infusion during surgery, and he is keen to see that the guidance navigates this contentious area for the benefit of patients.

What is the plan?

The new guidance will be based upon the latest evidence in perioperative diabetes care and will seek to include input from a wide range of stakeholders including patients, GPs, nurses, pharmacists, surgeons and anaesthetists.

Publication of the guideline is scheduled for October 2020, with further work envisaged to progress implementation of the guideline’s recommendations.

Resources to Help With the Diabetes Perioperative Pathway

E.Page, R.Allen, F. Wensley, G.Rayman (2020) Improving the peri-operative pathway of people with diabetes undergoing elective surgery.  DiabeticMedicine. DOI: 10.1111/dme.14307

Link to open access article.

Please read the full article here.

Aim

To determine whether outcomes for people with diabetes undergoing elective surgery improve following the introduction of innovations in the peri‐operative care pathway.

Methods

Following a baseline audit of 185 people with diabetes listed for elective surgery (July to December 2017) with a length of stay > 24 hours, a number of changes in practice were implemented. These included dissemination of a ‘diabetes peri‐operative passport’ to participants preoperatively, formation of a diabetes surgery working group, recruitment of surgical diabetes champions and the roll‐out of surgical diabetes study days. Crucial was recruitment of a diabetes peri‐operative nurse, whose role included engaging and educating others and supporting individuals throughout their peri‐operative diabetes care. Records of 166 individuals listed for surgery during the implementation period (July to December 2018) were then audited using the same methodology.

Results

The availability of a recent HbA1c measurement significantly increased (63% vs 92%; ≤ 0.001). The mean HbA1c of those seen for optimizations by the diabetes peri‐operative nurse significantly decreased [84 mmol/mol (9.8%) vs 62 mmol/mol (7.8%); ≤ 0.001]. Recurrent hypoglycaemia significantly decreased (7.0% vs 0.6%; = 0.002) and the mean number of hyperglycaemic events in people experiencing hyperglycaemia almost halved (3.0 vs 1.7; =0.007). The mean length of hospital stay significantly decreased (4.8 vs 3.3 days; =0.001) and, crucially, 30‐day readmissions did not increase (12% vs 9%; =0.307). Postoperative complications significantly decreased (28% vs 16%; =0.008), including a composite of dysglycaemic complications, poor wound healing, wound infection and other infections (12% vs 5.4%; =0.023).

Conclusion

The new pathway improved important peri‐operative outcomes for people with diabetes undergoing elective surgery with the potential for cost savings. These findings could have important implications for peri‐operative care on a wider scale.

The 'My Diabetes Passport: Planning For Surgery' allows patients and perioperative teams to document all a patients information during their journey to elective surgery throughout the pathway.

  • It has been shown that patients whose diabetes is well controlled before their operation are less likely to have complications and more likely to be discharged home earlier.
  • The aim of this perioperative diabetes passport is to help patients and the healthcare professionals looking after patients ensure that they are in the best possible condition for surgery and to make sure they receive the most appropriate care during inpatient stay.

Access the Diabetes Passport

The following resources are highly valuable for patients with diabetes undergoing day case surgery and staff treating patients on the day case diabetes pathway

Are you interested in the development of this guideline?
If you would like to know more or wish to become more involved in the work, please contact us.