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Diabetes patients let down by poor perioperative management

Report calls for national standard and policy to improve care

Jo Carlowe

Friday, 14 December 2018

Perioperative diabetes management requires improvement according to a new report, issued this week.

This latest National Confidential Enquiry in Patient Outcome and Death (NCEPOD) report* highlights the quality of diabetes care for patients aged 16 years or older who underwent a surgical procedure. The overarching theme of the findings was a lack of clinical continuity of diabetes management across the different specialties in the perioperative pathway.

Absence of joint ownership of the diabetes management and multiple guidelines targeted at specific specialties, rather than a joint multidisciplinary approach, meant that the diabetes management of the patient was falling between gaps in the surgical pathway, the report stated.

It noted that while diabetologists, anaesthetists and surgeons were commonly involved in the patient’s care, there was under involvement of key diabetes team members such as diabetes specialist nurses, dietitians and pharmacists.

Nutritional assessments and medicine reconciliations were frequently not undertaken, only 55.4% of patients had a MUST score calculated on admission to hospital and adequate medicines reconciliation by medical staff occurred in 84.4% of patients but only by a pharmacist in 75.3%. This was particularly noticeable for elective surgery where pre-operative assessment clinics should have provided opportunity for such reviews to be undertaken and a management plan developed and explained to the patient.

The management plan for a patient with diabetes undergoing surgery should include their prioritisation on the operating list. This study found that 19.4% of patients were not prioritised appropriately, which subjected them to prolonged fasting, putting them at increased risk of complications.

Regular monitoring of blood glucose was under-utilised pre-intra and post-operatively. It was the opinion of the reviewers that better monitoring would have helped facilitate the assessment of patient status.

Overall the report highlighted that there was room for improvement in the clinical care of 35.8% of patients in the study. This percentage was similar to that of good practice which was found in 34.8% of patients. Organisational systems of care were deemed to require improvement in 9.2% of cases reviewed and a further 14.1% of cases indicated improvements both in clinical and organisational systems of care.

The NCEPOD report made a number of recommendations including the need for the creation and implementation of a national joint standard and policy for the multidisciplinary management of patients with diabetes who require surgery.

Commenting on the report, Professor Gerry Rayman, Diabetes UK’s inpatient clinical lead, said: “We welcome the release of this report, which highlights significant problems in how people with diabetes who require surgery are cared for during their hospital stay. The report also makes sound recommendations on what needs to be done to improve care for people with diabetes requiring surgery.

“It’s now down to NHS trusts to ensure that the recommendations are adopted. These recommendations would go a long way towards improving the inpatient experience for people with diabetes undergoing surgery. They would also help to reduce the lengths of stay for people with diabetes, reduce mortality rates and minimise the harm associated with poor diabetes control.”

*Highs and Lows: A review of the quality of care provided to patients over the age of 16 who had diabetes and underwent a surgical procedure. A report prepared by the National Confidential Enquiry in Patient Outcome and Death, December 2018.

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