Improving the Perioperative Pathway for Patients with Diabetes

On 15th April 2021, GIRFT held a webinar on the topic of improving the perioperative pathway for patients with diabetes, with Professor Gerry Rayman, GIRFT joint clinical lead for diabetes, hosting. The full webinar can be viewed below.

Background

GIRFT data shows considerable variation in the length of stay (LoS) for patients with diabetes undergoing surgery

Nationally it is estimated that at least 330,000 surgical procedures are performed on patients with diabetes in the UK annually (100,000 of these as emergency procedures). Length of stay for patients admitted for surgery with diabetes is on average three days longer than those patients without diabetes, but in some hospitals this excess length of stay has been seen to be as much as 4.5 days. Furthermore, there are often inconsistencies in how trusts collect such data, making comparisons difficult.

A number of guidelines exist around the management of diabetes in the perioperative pathway but historically these have proven difficult to implement effectively in many hospitals. The multi-step perioperative pathway remains particularly challenging for patients with diabetes and there are a number of opportunities to increase patient experience and increase staff education in this area.

The IP3D model

A project at Ipswich Hospital to Improve the Perioperative Pathway for Patients with Diabetes (The IP3D project) has yielded positive results. The project 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 amongst 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 1.4 days and crucially patients report feeling more involved in their diabetes care. This new pathway has since been adopted by the trust and also expanded to include emergency surgery.  Key to the whole process has also been the establishment of an I3PD group- bringing staff together from surgery and diabetes and promoting closer and more consistent working relationships and communication between the specialities.

GIRFT and the IP3D Project

Based on the model used at Ipswich Hospital the IP3D project is being delivered by the GIRFT programme to ten trusts in the UK to see if the benefits realised at Ipswich Hospital can be replicated. The ten trusts who have signed up to the IP3D Project are:

  • Manchester University NHS Foundation Trust
  • Stockport NHS Foundation Trust
  • James Paget University Hospital
  • The Hillingdon Hospitals NHS Foundation Trust
  • St Georges University Hospital
  • Royal United Hospital Bath
  • University Hospitals of Leicester
  • Northampton General Hospital Trust
  • Portsmouth Hospitals NHS Trust
  • Hull University Teaching Hospitals

Each trust has received an initial visit from the GIRFT IP3D Programme Manager and over an 18 month period GIRFT is supporting trusts with the recruitment of a PeriopDSN and the setting up and implementation of the new perioperative pathway for people with diabetes. This new pathway includes the roll out of the diabetes perioperative passport, the adaptation of other IP3D resources and the establishment of pre-op optimisation clinics. GIRFT is also providing fortnightly coaching calls to each trust, group clinical calls for the newly recruited PeriopDSN’s and network meetings to bring the pilot sites together to map existing pathways and share learning.

The evaluation of the programme is being funded by NHSE and the overarching objectives are to:

  • Reduce length of stay of surgical patients.
  • Demonstrate a cost saving in bed days.
  • Reduce diabetes harms on surgical wards.
  • Improve the involvement of patients with diabetes in the perioperative pathway.
  • Improve patient satisfaction of perioperative care.
  • Provide a good understanding of what data specific to diabetes perioperative care can drive improvements.
  • Based on the learning in ten hospitals, to refine the key components for delivering improvements on a national basis

It is hoped that these objectives can be achieved by empowering the patient, providing increased education to staff and by promoting multidisciplinary working across surgery and diabetes.