Summary

Cardiac surgery outcomes are worse in patients with poorly controlled diabetes and an elevated HbA1c. Surgery may also be cancelled or delayed. This study assessed the effectiveness of a pharmacist-led diabetes pre-operative optimisation service (DPOS) in reducing HbA1c and enhancing cardiovascular optimisation prior to cardiac surgery. Patient consultations focused on a holistic approach to diabetes management in the context of impending surgery. Results demonstrated improved HbA1c and subsequent reduction in hospital length of stay. Interventions also resulted in improved cholesterol and hypertension management plus provision of lifestyle and dietary advice associated with improved long-term cardiovascular health.

Innovation

The challenge was to optimise diabetes care preoperatively to improve surgical outcomes and reduce hospital stays via a DPOS at the Royal Brompton & Harefield NHS Foundation Trust. The DPOS clinic took a holistic, multidisciplinary approach, surpassing traditional face-to-face consultations by integrating interventions tailored to each patient’s needs. Key innovations included holistic diabetes management, multidisciplinary collaboration, motivational interviewing and patient empowerment, flexible consultation formats, strategic governance and oversight, reduction of HbA1c levels, plus optimising blood pressure and cholesterol levels, with effectiveness measured using demographics, initial health status, interventions and outcomes.

Equality, Diversity and Variation

The initiative aimed to ensure equitable access, appropriate interventions and improved outcomes for all patients, regardless of background. The DPOS clinic offered flexible appointment options, including virtual consultations, to accommodate patients’ varying schedules and locations. Translation services and multilingual staff were employed to assist non-English speaking patients. Interventions were tailored to individual patients’ cultural, social and economic contexts. For example, dietary advice was adapted to include culturally appropriate food choices. Motivational interviewing techniques engaged patients in managing their health, considering their personal beliefs and circumstances. Staff received training in cultural competence. Outreach programmes were developed to educate communities about the importance of preoperative diabetes management and the services available. By offering virtual consultations and translation services, the clinic increased access for patients who previously faced geographical and language barriers. Customised care plans led to better engagement and adherence to preoperative optimisation protocols among patients from minority backgrounds. Patients reported feeling understood and respected. The clinic observed a reduction in HbA1c levels across all patient groups, indicating effective diabetes management. Length of hospital stay and post-operative complication rates showed a consistent decline, particularly among minority groups. Patient satisfaction surveys indicated high levels of satisfaction with the personalised and respectful care received.

Results

The DPOS demonstrated significant improvements in clinical outcomes over six months. HbA1c levels saw an average reduction of 16.7%. Baseline HbA1c levels were compared to levels just before surgery, demonstrating substantial improvement in glycaemic control. The average length of preoperative and postoperative hospital stays was reduced. Preoperative stays were shortened to 0-5 days for 95% of clinic patients compared to 81% of non-clinic patients. Postoperative stays also saw a significant reduction, indicating faster recovery times and fewer complications. There was a decrease in postoperative complications, such as infections and wound healing issues, directly correlating with better preoperative diabetes management. Tailoring care to individual patient needs resulted in improved patient satisfaction and adherence to treatment protocols. Through motivational interviewing and continuous support, patients were more engaged and proactive in managing their diabetes. Shorter hospital stays reduced the strain on hospital resources, allowing better allocation of beds and reducing risk of hospital-acquired infections. Virtual consultations increased accessibility and reduced the need for in-person visits, saving time for both patients and healthcare providers. The comprehensive approach addressed not just blood glucose levels but also blood pressure, cholesterol, diet, exercise, smoking cessation and alcohol reduction. Multidisciplinary collaboration ensured cohesive and comprehensive care. Regular follow-ups and continuous monitoring helped maintain patient progress and quickly address any issues. The project was funded through a combination of internal NHS resources and potential grants aimed at improving patient care and outcomes. It proved cost effective and economically viable.

User Feedback

The initiative garnered significant support from stakeholders, including healthcare professionals and service users. Based on feedback, the clinic introduced more flexible scheduling options with 30-minute appointments. Patients could choose how they were reviewed. The frequency of follow-up consultations was adjusted to ensure patients received adequate support, particularly during critical pre-operative periods. Improved educational materials were developed to provide clearer guidance on managing diabetes and preparing for surgery.

Dissemination and Sustainability

The project has garnered interest from other healthcare organisations, suggesting potential for wider adoption and influence across the NHS and possibly beyond. The success of virtual consultations highlights the potential for further expanding telehealth services. Increasing the availability of virtual follow-ups and remote monitoring tools and digital tools can enhance patient convenience and continuity of care. Developing more comprehensive educational resources, including online tutorials and interactive platforms, can provide ongoing support and information to patients. This can help maintain engagement and adherence to care plans beyond the preoperative period. Extending outreach programmes to educate broader communities about the importance of diabetes management and preoperative optimisation can increase awareness and uptake of such services. Collaborations with local organisations and primary care providers can support this effort. Utilising data collected from patient outcomes and feedback can continuously refine and improve the service. Implementing advanced data analytics can help identify trends, predict outcomes and tailor interventions more effectively. The DPOS initiative’s framework makes it relatively straightforward for other healthcare services to implement.