Summary

Patients with diabetes have complex medical needs, which are heightened when faced with surgical intervention. St George's University Hospitals NHS Foundation Trust introduced a diabetes specialist pharmacist to the preoperative setting, in order to optimise and pre-empt medicines management issues pre-surgery, and to collaborate and better utilise skill sets of other healthcare professionals. From pre-operative care to theatres, recovery, ward and finally discharge, pharmacists ensured bespoke plans were actioned and communicated, with excellent feedback from surgeons, anaesthetists and diabetes team. Since completion of this work, the data has been fed back to the Trust chief executive with the creation of permanent pharmacist support. There has since been a drive to upskill pharmacy workforce through specialist diabetes workshops and simulation projects to support patients.

Results

One hundred and five patients were seen, with 100% receiving a written management plan with active patient/carer participation, glycaemic control scrutinised, then optimised, given preventative health screening and interventions performed. Pre-made clinical decisions helped reduce length of fasting time, reduce prescribing of unnecessary insulin infusions and selecting appropriate insulin scale in advance where required. Admission blood sugars were within 4-12mmol/L and patients were actively placed on the first third of the operating list as recommended, avoiding unnecessary admission night before, therefore intravenous insulin need. This lead to active avoidance of 10 cancellations due to poor glycaemic control contrasting with 2-3/ month prior to intervention. Cancellation avoidance and promotion of same day admission led to estimated savings of upward of at least £35,000. Patient safety improved as diabetes medication related error reporting subsided.

Challenge

Diabetes is one of the most common chronic disorders, affecting at least 6% of people in the UK with the prevalence rising. Patients with diabetes have complex medical needs, but often overlooked are the increased risk of surgical interventions in this group due to diabetes related co-morbidities. As a result at least 10% of patients undergoing surgery will have diabetes and in some hospitals as many as 30%. Failure to identify patients before admission increases the risk of errors. Service provision delivered to the elective surgical diabetes patient did not separate and highlight their specific needs or recognise numerous benefits diabetes patients would receive from dedicated input.

Objectives

These were numerous, and included 100% of peri-operative management plans to be created and implemented with active patient participation, preventative screening and meal plan to reduce fasting period and requirement for intravenous insulin. Also, to highlight and manage patients with poor glycaemic control and encouraging patients to self-manage confidently by promoting patient ownership and control. Other aims included preventing cancellations, reducing delayed discharges from hospital and reducing overall length of stay.

Solution

For the first time a pharmacist-led specialist diabetes pre-operative clinic was introduced for two days a week over four months from September 2014 with support of the South West London Small Grants Scheme. Patients were referred directly to the specialist pharmacist by pre-operative care HCPs. During consultation with the pharmacist, patients were for the first time:

• Assessed using a specially designed proforma to identify surgical needs and troubleshoot,
• Optimised glycaemic control pre-surgery to acceptable limits,
• Performed NICE-guided preventative screening
• Provided with a plan with education/advice for patients and HCPs on interruption of diabetes treatment for surgery.

Patients identified as high risk were directly referred for more specialist input from the diabetologist. Other key HCPs were liaised with as necessary in the surgical pathway. Any pre-surgical actions were communicated as appropriate to the patient/HCPs to complete prior to surgery. The outcomes were dependent on implementation of the specialist pharmacist designed plan by other HCPs.

Learnings

The work captured the interest of a variety of HCPs and uniquely bridged the gap between the wider multidisciplinary team. The identification and referral of patients by pre-operative staff to the specialist pharmacist meant clinical issues as a direct result of diabetes and medication were able to be proactively resolved well in advance of the planned surgery, as opposed to previous practice of troubleshooting on the day by inexperienced clinical staff. Patients identified as complex had specialist input from an experienced diabetologist. This previous reactive approach lead to inefficient working practices affecting patient fl ow and potential risk surrounding inappropriate medication interruption. With the new approach, pre-operative staff highlighted the benefits of being able to refer to a specialist and focus attention to their area of expertise. This positively impacted both patient and clinician satisfaction. A greater emphasis is required on referral process across all surgical areas in order to target patients requiring support and optimisation. During the initiative HCPs came to learn the importance of properly managing diabetes patients as the benefits directly impacted their working practices. However in order for this to have a greater impact across the Trust, the benefit of the referral process needs to be shared. This requires a strong focus on education and training to promote the service to the wider hospital group.

Evaluation

Although the aims and objectives appear to be extensive, they are highly achievable due to the simple notion behind the service – to engage the patient proactively and prospectively provide clinical management plans for the peri-operative period. This straightforward idea has impacted directly on improving clinical objectives thereby in turn, service outcomes and user satisfaction. One of the more challenging aspects was to achieve for 100% of patients to maintain glycaemic control within a range of 4-12mmol/L throughout the perioperative period. Although the admission blood glucose could be targeted pre-operatively, in practice maintaining control thereafter is a difficult clinical outcome to achieve as it is subject to various clinical influences. However it is thought with a focus on education and training to the relevant staff, the impact on the variations may be minimised.