PATI ENT OP TIMI SATION
in diabetes management of perioperative patients by their local diabetes teams and by GIRFT – via shadowing, network sessions, e-learning, coaching calls and fortnightly 1:1 support.
Successes from the pilots included: l Significant improvements in patient safety: Overall, there was a 71% reduction in patients with diabetes who experienced diabetes-related harm or complications, from 14% to 4%. These can include hyper- and hypoglycaemic events, foot ulcers, diabetic ketoacidosis (DKA) and poor wound healing.
l Less time spent in hospital: Length of stay (LoS) for elective surgery inpatients with diabetes fell from an average of 5.1 to 4.2 days, with one Trust seeing a 41% reduction. LoS for patients with diabetes who had day surgery fell from 0.93 to 0.39 days, while LoS for patients with diabetes admitted as an emergency fell by five days, from 12.6 to 7.4 days.
lA better experience for patients: In a post-pilot survey, patients with diabetes noted improvements in seven out of nine areas of their perioperative care, and many commented on the positive impact their PeriopDSN had on their stay.
l Improved staff knowledge: Knowledge improved considerably during the project and confidence increased, particularly in the area of hyperglycaemia management.
Emma Page said: “One of the best outcomes was the feedback from patients, who commented how they had seen an improvement in their care and what a difference the PeriopDSN had on their stay in hospital. The general feeling was that the patient experience was less stressful and ran more smoothly due to their presence, which is the most important outcome of all.” Speaking at a GIRFT webinar on improving the perioperative pathway,13
Kim
Howson, diabetes perioperative specialist nurse, James Paget University Hospitals, also highlighted the impact on patient experience: “Often patients have their operations cancelled at the last minute due to poor glycaemic control. Patient surveys show that patients wish they had known sooner so they could have done something about it. They are left frustrated and disappointed over delays in their surgery.”
She highlighted the fact that patients designated for day case surgery may also have to be converted to an overnight stay in hospital if their diabetes has not been managed prior to surgery. During lockdown, many patients with diabetes saw an exacerbation of their condition. “Some patients have experienced such a decline of their renal function by the time they have seen us that it actually limits the
treatment options available,” she reported. She explained that good glycaemic control prior to surgery involves engaging patients in their diabetes management, optimising diabetes, and other conditions prior to surgery where possible. “Patients are often very motivated to have their surgery as it may make a big difference to their day-to-day lives, so we have a real opportunity to engage patients in their self- management. Often, lifestyle changes that people make for their diabetes are beneficial to other health conditions,” she continued. She added that effective management not only improves patient experience but can also make better use of NHS resources and improve capacity in the system: “With improved information, in our automated patient summaries, we can better identify patients at risk of severe complications early. This is not just about improving the patient’s experience around surgery, but also about helping them to have a recovery that doesn’t involve trips to their GP for antibiotics or extended district nurse visits for wound care. By reducing the length of stay at hospital, we are going to enable more people to have their surgery sooner.” This is particularly relevant, in view of the backlog caused by the pandemic, she pointed out. “Ultimately, it is up to us all to make the most of those teachable moments, to engage patients in their diabetes management, even by simply making people aware that good blood glucose control can improve their recovery,” she concluded. “Even with a two-week improvement in glycaemic control, the person’s white cell function can be improved. We should optimise health conditions where possible and, for some, we can enable much longer lasting health benefits.”
Discussions are now under way to expand the programme, potentially recruiting more PeriopDSNs and developing an IP3D learning course and an emergency surgery IP3D pathway.
References 1. Rayman, G & Kar, P, Diabetes: GIRFT Programme National Specialty Report, November 2020. Accessed at:
https://www.gettingitrightfirsttime.
co.uk/wp-content/uploads/2022/01/GIRFT- diabetes-report.pdf
2. Wang J, Chen K, Li X, et al. Postoperative adverse events in patients with diabetes undergoing orthopedic and general surgery. Medicine (Baltimore). 2019;98(14):e15089. doi:10.1097/ MD.0000000000015089
3. Zhang X, Yan X, Gorman J, et al. Perioperative hyperglycemia is associated with postoperative neurocognitive disorders after cardiac surgery. Neuropsychiatr Dis Treat, 2014;10:361-70.
4. Clarke RS. The hyperglycaemic response to different types of surgery and anaesthesia. Br J Anaesth 1970;42:45–53.
72 l
WWW.CLINICALSERVICESJOURNAL.COM
5. Maruyama K, Sato S. Effect of high-glucose conditions on human periodontal ligament endothelial cells: in vitro analysis. Odontology, 2017;105:76–83.
6. Donatelli F, Vavassori A, Bonfanti S, et al.Epidural anesthesia and analgesia decrease the postoperative incidence of insulin resistance in preoperative insulin-resistant subjects only. Anesth Analg 2007;104:1587–93.
7. Hommel I, Van Gurp PJ, Den Broeder AA, et al. Reactive rather than proactive diabetes management in the perioperative period. Horm Metab Res 2017;49:527–33.
8. Frisch A, Chandra P, Smiley D, et
al.Prevalence and clinical outcome of hyperglycemia in the perioperative period in noncardiac surgery. Diabetes Care 2010;33:1783–8.
9. NCEPOD, Perioperative Diabetes: High and Lows, 13th December 2018, Accessed at: https://www.
ncepod.org.uk/2018pd.html
10. National Diabetes Inpatient Audit, 2019. Accessed at:
https://digital.nhs.uk/data-and-information/ publications/statistical/national-diabetes-inpatient- audit/2019
11. Centre for Perioperative Care, Guideline for Perioperative Care for People with Diabetes Mellitus Undergoing Elective and Emergency Surgery, March 2021. Accessed at: https://www.
cpoc.org.uk/sites/cpoc/files/documents/2021-03/ CPOC-Guideline%20for%20Perioperative%20 Care%20for%20People%20with%20Diabetes%20 Mellitus%20Undergoing%20Elective%20and%20 Emergency%20Surgery.pdf
12.
https://cpoc.org.uk/sites/cpoc/files/ documents/2020-05/Diab%20Med%20IP3D%20 Peri-op%20print_0.pdf
13. GIRFT webinar on ‘improving the perioperative pathway for patients with diabetes’, 15 April 2021.
https://www.gettingitrightfirsttime.co.uk/improving- the-perioperative-pathway-for-patients-with- diabetes/
Leaflet for patients CSJ
A leaflet to help people with diabetes stay healthy in the lead-up to elective surgery has been produced. Professor Gerry Rayman MBE (consultant diabetologist and GIRFT joint clinical lead for diabetes), along with Emma Page (GIRFT workstream delivery manager), Dr. Nico Zin (anaesthetist) and Dr. Rose Stewart (clinical psychologist), worked with surgeons, anaesthetists and staff in pre-operative assessment units to develop the guide, which encourages patients to maintain healthy glucose levels, keep their feet healthy, reduce stress levels and take part in healthy activities while they wait for surgery. To download the leaflet, visit: https://abcd. care/sites/
abcd.care/files/site_uploads/ Resources/GIRFT-Keeping-well-while- you-wait-for-your-operation.pdf
NOVEMBER 2022
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76
