The benefits of proactive pre and perioperative diabetes management in a DGH setting'

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The benefits of proactive pre- and perioperative
diabetes management in a DGH setting.

• Torbay Hospital, Torquay.
• Margaret Blackmore, Sharon Wilkes, Sarah Thorne,
  Charlotte Heppenstall, Anna Lemonides Rob Dyer
  (Diabetes)
• Mary Stocker and Melanie Hearne, Annette Bell
  (Anaesthetics)

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Background

• Many theoretical reasons why good pre and
  perioperative glycaemic control in diabetic
  patients is important
• Recent evidence for reduced adverse outcomes in
  cardiac and orthopaedic patients ( ITU)
• National and international data shows diabetic
  patients have poorer surgical outcomes and longer
  length of stay than non-diabetic patients

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CITEC project Jan 2007 to Jan 2008

• Torbay data 2004-5 showed
• LoS 160 for emergency and 135 for elective
  surgery
• Day surgery rates lower for diabetes 51 vs 62
• Aims of project
• to reduce LOS by 40
• To increase proportion of diabetic patients
  through day surgery
• Improved experience for patients (and reduced
  risk)

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Diabetes perioperative project 2004 -2008

• Development and training of Diabetes Specialist
  Nurse (DSN) with particular role in care of
  inpatients (2003-4)
• Intensive pre- and perioperative specialist nurse
  and dietetic input for patients with poor control
  and at high risk (2004)
• Rewriting of perioperative diabetes management
  guidelines including advice to facilitate day
  case management (2005).
• Development of more robust clinical pathways
  through discussion with anaesthetic staff (2006 -
  )
• Development of preassessment of inpatients and
  day cases with educational support for staff
  (2004-5)
• Introduction of standardised information for
  patients (2006)
• Advice for diabetic patients undergoing surgery
  telephone (2006)
• Early identification of patients as they are
  listed for surgery through PTL linkage with
  diabetes database (2007)
• Dissemination of results and discussion of new
  pathways in secondary care where greatest benefit
  anticipated (2007)
• Raising awareness of need for good perioperative
  control in primary care And development of
  referral pathways (2007-8)

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Diabetes perioperative project 2004 -2008

• Development and training of Diabetes Specialist
  Nurse (DSN) with particular role in care of
  inpatients (2003-4)
• Intensive pre- and perioperative specialist nurse
  and dietetic input for patients with poor control
  and at high risk (2004)
• Rewriting of perioperative diabetes management
  guidelines including advice to facilitate day
  case management (2005).
• Development of more robust clinical pathways
  through discussion with anaesthetic staff (2006 -
  )
• Development of preassessment of inpatients and
  day cases with educational support for staff
  (2004-5)
• Introduction of standardised information for
  patients (2006)
• Advice for diabetic patients undergoing surgery
  telephone (2006)
• Early identification of patients as they are
  listed for surgery through PTL linkage with
  diabetes database (2007)
• Dissemination of results and discussion of new
  pathways in secondary care where greatest benefit
  anticipated (2007)
• Raising awareness of need for good perioperative
  control in primary care And development of
  referral pathways (2007-8)

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Diabetes perioperative project 2004 -2008

• Development and training of Diabetes Specialist
  Nurse (DSN) with particular role in care of
  inpatients (2003-4)
• Intensive pre- and perioperative specialist nurse
  and dietetic input for patients with poor control
  and at high risk (2004)
• Rewriting of perioperative diabetes management
  guidelines including advice to facilitate day
  case management (2005).
• Development of more robust clinical pathways
  through discussion with anaesthetic staff (2006 -
  )
• Development of preassessment of inpatients and
  day cases with educational support for staff
  (2004-5)
• Introduction of standardised information for
  patients (2006)
• Advice for diabetic patients undergoing surgery
  telephone (2006)
• Early identification of patients as they are
  listed for surgery through PTL linkage with
  diabetes database (2007)
• Dissemination of results and discussion of new
  pathways in secondary care where greatest benefit
  anticipated (2007)
• Raising awareness of need for good perioperative
  control in primary care And development of
  referral pathways (2007-8)

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Diabetes perioperative project 2004 -2008

• Development and training of Diabetes Specialist
  Nurse (DSN) with particular role in care of
  inpatients (2003-4)
• Intensive pre- and perioperative specialist nurse
  and dietetic input for patients with poor control
  and at high risk (2004)
• Rewriting of perioperative diabetes management
  guidelines including advice to facilitate day
  case management (2005).
• Development of more robust clinical pathways
  through discussion with anaesthetic staff (2006 -
  )
• Development of preassessment of inpatients and
  day cases with educational support for staff
  (2004-5)
• Introduction of standardised information for
  patients (2006)
• Advice for diabetic patients undergoing surgery
  telephone (2006)
• Early identification of patients as they are
  listed for surgery through PTL linkage with
  diabetes database (2007)
• Dissemination of results and discussion of new
  pathways in secondary care where greatest benefit
  anticipated (2007)
• Raising awareness of need for good perioperative
  control in primary care And development of
  referral pathways (2007-8)

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Diabetes perioperative project 2004 -2008

• Development and training of Diabetes Specialist
  Nurse (DSN) with particular role in care of
  inpatients (2003-4)
• Intensive pre- and perioperative specialist nurse
  and dietetic input for patients with poor control
  and at high risk (2004)
• Rewriting of perioperative diabetes management
  guidelines including advice to facilitate day
  case management (2005).
• Development of more robust clinical pathways
  through discussion with anaesthetic staff (2006 -
  )
• Development of preassessment of inpatients and
  day cases with educational support for staff
  (2004-5)
• Introduction of standardised information for
  patients (2006)
• Advice for diabetic patients undergoing surgery
  telephone (2006)
• Early identification of patients as they are
  listed for surgery through PTL linkage with
  diabetes database (2007)
• Dissemination of results and discussion of new
  pathways in secondary care where greatest benefit
  anticipated (2007)
• Raising awareness of need for good perioperative
  control in primary care And development of
  referral pathways (2007-8)

9
Diabetes perioperative project 2004 -2008

• Development and training of Diabetes Specialist
  Nurse (DSN) with particular role in care of
  inpatients (2003-4)
• Intensive pre- and perioperative specialist nurse
  and dietetic input for patients with poor control
  and at high risk (2004)
• Rewriting of perioperative diabetes management
  guidelines including advice to facilitate day
  case management (2005).
• Development of more robust clinical pathways
  through discussion with anaesthetic staff (2006 -
  )
• Development of preassessment of inpatients and
  day cases with educational support for staff
  (2004-5)
• Introduction of standardised information for
  patients (2006)
• Advice for diabetic patients undergoing surgery
  telephone (2006)
• Early identification of patients as they are
  listed for surgery through PTL linkage with
  diabetes database (2007)
• Dissemination of results and discussion of new
  pathways in secondary care where greatest benefit
  anticipated (2007)
• Raising awareness of need for good perioperative
  control in primary care and development of
  referral pathways (2007-8)

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Numbers of surgical inpatients (all surgical
specialties)
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5
7
6
6
5
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Excess length of stay for diabetic patients (all
surgical specialties)
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Percentage of patients treated as day case (All
surgical specialties)
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Percentage of patients treated as day case
(Excluding Opthalmology)
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Bed days Saved through diabetic team input (most
conservative estimate!)

• Elective (minus LOS reduction for all patients of
  15)
• 165 bed days
• Conversion to day case (2004-7)
• 420
• Emergency (assuming LOS reduction 7)
• 1229 bed days
• Total 1814

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Biggest potential gains in day case utilisation
through change in diabetes pathway
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Biggest potential gains in day case utilisation
through change in diabetes pathway
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Biggest potential gains in day case utilisation
through change in diabetes pathway
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Other preliminary findings

• Database misses some diabetic patients
  potential for even greater benefits
• Further potential gains from conversion to day
  surgery, approx 400 beds per annum
• Difficulties encountered with standardisation of
  ward protocols
• Potential benefits in terms of quality of
  experience, self management
• Reduction in clinical risk

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Message

• Improved efficiency and safety of management of
  surgical patients may come from development of
  relationships outside the surgical specialties.

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• THANKYOU

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Change in Length of Stay 2004- 2007
Mean LOS Diabetes
Mean LOS Non-diabetic
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Diabetic patients 2004-2007
Numbers of admissions
Total bed days occupied
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Variation in Day Case utilisation by specialty