PATI ENT OP TIMI SATION
Optimising surgery for patients with diabetes
Poor management of diabetes can have a serious impact on surgical outcomes, increasing the risk of complications and mortality. Discussions are underway to scale up a pilot programme, with the aim of transforming surgical pathways, to help reduce complications and reduce length of stay.
In 2020, a Getting it Right First Time (GIRFT) national report1
highlighted that up to 20%
of all hospital beds in England are occupied by people with diabetes, although most (92%) are admitted for other conditions and illnesses. Around 330,000 surgical procedures are carried out on people with diabetes in the UK annually, and their length of stay (LoS) in hospital is, on average, three days longer than patients without diabetes (four days for those admitted as an emergency). Based on these figures, it is estimated that surgery on patients with diabetes accounts for 15% of all operations – so how can we improve outcomes for this significant cohort of patients? A number of reports have highlighted the need to improve the management of diabetes for patients undergoing surgery, in recent years. Patients with poorly managed diabetes have higher rates of complications post-
surgery – as well as longer hospital stays – but some healthcare providers fail to get the basics right when it comes to optimising and monitoring diabetes.
Throughout the surgical pathway, missed
opportunities, avoidable errors and poor communication can result in increased risk of: surgical site infection, poor wound healing, hospital-acquired diabetic ketoacidosis, post- operative sepsis, endothelial dysfunction and cerebral ischaemia.2-8
Furthermore, patients
with poorly managed diabetes are known to have a significantly lower survival rate post- operatively.2,3
In December 2018, A National Confidential Enquiry into Patient Outcome and Death (NCEPOD) identified significant issues around the perioperative management of people with diabetes – a staggering 60% did not have a clear plan for the management of their diabetes on the day
of their surgery and over 43% pre-operative assessment clinics did not have a specific policy for management of people with diabetes undergoing surgery. The report, Perioperative Diabetes: High
and Lows, also found: l41% of referrals had no information on the management of the patient’s diabetes in the community.
lOnly 42% of patients referred electively had their HbA1c measured in the previous three months.
l9.3% of hospitals did not have a protocol for the perioperative management of people with diabetes.
l33.2% of hospitals where elective surgery was performed, and 16.1% of hospitals where emergency surgery was performed, had no routine use of risk scoring systems prior to surgery.
lOnly 28.0% of hospitals had a named clinical lead for perioperative diabetes.
lIn theatre and recovery, guidelines advocate regular capillary blood glucose (CBG) monitoring, yet 14% of patients did not have adequate in-theatre CBG monitoring and intraoperative hypoglycaemia occurred in 4.7%.
l69.6% of hospitals used paper-based systems to prescribe insulin (despite an increased risk of human errors associated with paper-based systems.)
l21% of patients did not have their blood glucose managed appropriately in the post- operative period.
NCEPOD highlighted a number of key issues that needed to be addressed, including: a lack of clinical continuity of diabetes management across the different specialties in the perioperative pathway; an absence of joint ownership of diabetes management; multiple guidelines targeted at specific specialties,
NOVEMBER 2022
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