Perioperative management of diabetes in major surgery in Gloucestershire Royal Hospital

Background

Optimal peri-operative management of glucose control in diabetic patients is essential. GRH collects data on patients undergoing major surgery as part of PQIP since 2018 and identified diabetes management for improvement. Key indicators included measuring HbA1c on all diabetic patients before major elective surgery and consider postponing non-urgent surgery if HbA1c>8.5%. Other recommendations include measuring blood glucose regularly and aiming for blood glucose levels of 6-12 mmol/l throughout surgery.

Method

We looked at the GRH PQIP database after 6 months of recruitment to identify patients with Type 1 or Type 2 diabetes. We audited the perioperative management of diabetes against key indicators to identify areas for improvement.

Reviewing our trust guidelines and PQIP recommendations we set our standards:

• 100% of patients will have an HbA1c measured before major elective surgery
• Postponing non-urgent surgery will be considered if HbA1c>8.5% in 100% of cases
• 100% patients will have a capillary blood glucose (CBG) measured on admission
• 100% of patients will have CBG measured hourly in the perioperative period
• Blood glucose levels will be kept at 6-12 mmol/l throughout surgery in 100% cases
• Variable rate insulin infusions (VRII) will be used if blood glucose >12 mmol/l in 100% cases

Results

We identified 14 patients with diabetes out of a database of 86 cases (16%). All cases were elective, from September 2018 – February 2019. Of the 14 cases, 5 were treated with insulin, 5 with non-insulin glucose lowering medication and 4 were diet controlled.

None of the standards were met.

• 71% had an HbA1c measured, and in 29% the HbA1c was >8.5%.
• Out of the 4 cases with an HbA1c>8.5%, 3 were not delayed due to surgical urgency.
• 71% had a CBG measured on admission.
• 43% had a VRII appropriately commenced when CBG>12 mmol/L.
• 29% maintained CBG between 4-12 in the perioperative period.
• None recorded hourly perioperative CBG’s.

Conclusion

Our results have identified intraoperative measurement and documentation of CBG requires significant improvement. No cases recorded hourly perioperative glucose measurement. Several cases had no documentation at all throughout surgery. We have also identified not all patients had an HbA1c measured. Comparing our data with the national PQIP data, GRH has a higher proportion of diabetic patients (16% vs 13%) and those with an elevated HbA1c (29% vs 20%). In order to improve practice, we introduced pre-operative assessment nurse training sessions, are establishing a nurse champion to assist with diabetic queries pre-operatively, referring high risk cases for post-op diabetic nurse follow up and forming a joint working group with diabetic liaison nurses to review the current pathway and assess impact of new insulin regimes and pumps.