PATI ENT OP TIMI SATION
rather than a joint multidisciplinary approach, creating gaps in the surgical pathway; under- involvement of key diabetes team members; nutritional assessments and medicine reconciliations were frequently not undertaken; patients were not prioritised appropriately, which subjected them to prolonged fasting; and regular monitoring of blood glucose was under-utilised pre-, intra- and post-operatively.9 In 2019, the National Diabetes Inpatient Audit (NaDIA) also found: lHigh levels of insulin errors – two fifths of inpatient drug charts for insulin-treated inpatients had one or more insulin error.
lOn the day of the audit, 3.6% of inpatients with type 1 diabetes had developed hospital-acquired diabetic ketoacidosis during their hospital stay.
lCapillary blood glucose (CBG) levels were not being recorded at all recommended stages of the perioperative pathway.10
Guidance So, what exactly should best practice look like and how can we begin to improve the care provided for surgical patients with diabetes? The Centre for Perioperative Care (CPOC), working in partnership with Diabetes UK, has recently updated its guidance for the care of people with diabetes undergoing surgery – encompassing the whole of the perioperative pathway. The guideline, which was commissioned
by the Academy of Medical Royal Colleges,11 outlined a series of recommendations for all stakeholders in the patient’s journey – from primary care teams, to staff working in preoperative assessment services, surgical teams, staff working in theatre and recovery, and patients themselves.
It stated that the surgical pathway should include the following steps:
Referral
Standardised referral form including: lHbA1c within three months of referral lControl of co-morbidities lAll medications
Before surgery Assess and optimise: ldiabetes lcomorbidities.
Ensure shared decision making. Use surgery as a teachable moment for: lWeight management lExercise lSmoking cessation
If HbA1c over 69mmol/mol (8.5%) refer for optimisation.
Planning
Develop an individualised plan for: lPre- and post-surgery medication changes lDay surgery or inpatient surgery lTiming of surgery
Communicate plan with patient, GP and all relevant staff.
On admission lEnsure medicines reconciliation lUse pre-operative plan lMaintain CBG at 6–12 mmol/l lDocument CBG, renal profile, lactate, ketones in emergency patients
lEnsure patients with Type 1 diabetes are never denied insulin
The IP3D pathway has been hugely successful since it was introduced in Ipswich, and has made a real difference to the care which people with diabetes receive. The passport empowers the patients so that they understand what good care looks like and are aware of any issues which may arise so that
they are able to ask informed questions. Professor Gerry Rayman MBE, GIRFT joint clinical lead for diabetes.
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In theatre lMinimise fasting period lMaintain CBG at 6–12 mmol/l lAim for early DrEaMing lClear diabetes management handover
On return to the ward lEnsure medicines reconciliation lEncourage early DrEaMing lProtect pressure areas lEnsure patients with Type 1 diabetes are never denied insulin
lMaintain CBG at 6–12 mmol/l lRefer to diabetes specialist teams according to criteria
On discharge
Communicate with patients and GPs re: lAll medication changes lPlan for future diabetes care lImportance of self-management
While there are too many recommendations to list in this article, some of the key messages for providers included: lCommissioning bodies should work collaboratively with primary, secondary, community and social care services to develop perioperative pathways for people with diabetes. They should consider commissioning pre-operative holistic assessment and optimisation (including prehabilitation) services for people with diabetes and co-existing co-morbidities. The focus should be on improving both short-term perioperative outcomes and long-term health outcomes.
lAll organisations involved in supporting people with diabetes through the perioperative pathway, should ensure staff have access to and complete regular training in the relevant aspects of diabetes management
lAll hospitals, where surgical services are provided, should appoint a clinical lead for perioperative diabetes care.
NOVEMBER 2022
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