PATI ENT OP TIMI SATION
lHospitals should appoint a specific team to co-ordinate individualised perioperative care for people with diabetes. This task should be supported by perioperative diabetes inpatient specialist nurses (DISNs) with appropriate clinical support.
lHospitals should invest in technologies to support perioperative care of people with diabetes – i.e. so that all people with diabetes can be routinely identified on the patient administration electronic systems, and alerts are given for glucose levels, for example tagging of electronic medical records.
lHospitals should ensure systems are in place to support self-management for people with diabetes, while waiting for surgery and immediately pre- and post- operatively in hospital.
lThere should be clear written information for people with diabetes about what they can do to prepare for surgery, as well as information on the care they can expect around the management of their diabetes in the perioperative period and their involvement in their care.
Getting it Right First Time: The Ipswich model To help reduce complications and length of stay, GIRFT has also recommended that all Trusts should have clear, audited perioperative pathways for people with diabetes, as well as a perioperative diabetes team. Some excellent progress has already been achieved and work is underway to roll- out further improvements across the NHS. According to an independent post-pilot
evaluation, a GIRFT-led pilot project has proven successful in improving the care of people with diabetes before, during and after surgery. Improvements in patient safety, fewer complications, less time spent in hospital and a better overall patient experience were among the benefits demonstrated, as a result of the Improving
the Perioperative Pathway of Patients with Diabetes (IP3D) programme.
The project, led by GIRFT joint clinical lead for diabetes, Professor Gerry Rayman MBE, and workstream delivery manager Emma Page, was first modelled at Ipswich Hospital. It is based around the concept of a ‘perioperative passport’ that is designed to empower the patient along their surgical journey by providing them with all the necessary information required before, during and after their operation and used as a shared resource between patient and clinicians involved in their care. This pathway is supported by a perioperative diabetes specialist nurse (PeriopDSN) who provides education and support to patients both pre- and post- operatively, as well as working to improve diabetes education among surgical staff. Surgical study days are held bi-annually, and each surgical area or ward has their own dedicated diabetes perioperative champion who links in regularly with the perioperative diabetes nurse.
The perioperative nurse attends weekly huddles in the various preoperative assessment units and, along with the project manager, has worked on improving a number of processes in the perioperative pathway, including the pathway documentation for day-case patients and the management of hyperglycaemia. A robust audit protocol was developed, and data was collected from patient records. Length of stay in elective patients has so far reduced by 1.5 days and, crucially, patients report feeling more involved in their diabetes care.12
This new pathway has since been expanded to include emergency surgery. Key to the whole process has been the establishment of an IP3D group – bringing staff together from surgery and diabetes care and promoting closer and more consistent working relationships and communication between the specialties.
Prof. Gerry Rayman, said: “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. This also has a really positive knock-on effect of helping to educate staff working on our surgical wards about the potential complications linked to diabetes. “This is especially important as patients whose diabetes is poorly controlled before their procedure are more likely to face complications after surgery, such as infections, slow-healing wounds and cardiovascular issues such as heart attacks. It is also vital that any medication they are prescribed is carefully monitored so that it doesn’t interact with the drugs they are already taking to manage their diabetes, and that some specific diabetes drugs are stopped before surgery.”
In 2019, GIRFT replicated the Ipswich model and rolled it out across another 10 pilot Trusts, to see whether similar improvements could be achieved. The 10 Trusts which took part in the pilot were: lManchester University NHS Foundation Trust (NW region)
lStockport NHS Foundation Trust (NW region)
lJames Paget University Hospitals NHS Foundation Trust (EoE region)
lThe Hillingdon Hospitals NHS Foundation Trust (London region)
lSt George’s University Hospitals NHS Foundation Trust (London region)
lRoyal United Hospitals Bath NHS Foundation Trust (SW region)
lUniversity Hospitals of Leicester NHS Trust (Midlands region)
lNorthampton General Hospital NHS Trust (Midlands region)
lPortsmouth Hospitals NHS Trust (SE region)
lHull University Teaching Hospitals NHS Trust (NE region)
Prof. Rayman commented: “It was important that Trusts were able to adapt the IP3D pathway to their local needs, and we were keen to support that. It was pleasing to see a number of innovations emerge, including dedicated diabetes surgical study days, working with primary care to improve surgical referrals and, in one Trust, establishing a diabetes perioperative dashboard.”
Each of the ten pilot sites recruited a perioperative diabetes specialist nurse whose role was to provide pre-optimisation clinics and improve diabetes education among staff. These nurses were supported with training
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