Senior Nurse. (Diabetes)

Transcription

1 Annual C onference 6 th Novem mber 2008 Royal Court Hotel, Coventry

2 Pre-assessment and the patient with diabetes. Louise Hilton Senior Nurse (Diabetes) BoltonPCT PCT.

3 Bolton.

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5 Introdu uction. Diabetes is an endocrine condition affecting 2.5 million people in the UK, estimated 1 million undiagnosed (Diabetes UK). Type 1/ Type 2 diabetes. 14,000 people with diabetes 15-20% of all hospital admissions. within Bolton.

6 Diabe etes. People with diabetes at increased risk of developing perioperative complications. (Rahman & Beattie 2004). Raised blood glucose levels can lead to delayed wound healing and an increased risk of contracting postoperative infections. Acute physical stress of surgery can lead to acute hyperglycaemia by the supp pression of insulin release which could lead to diabetic ketoacidosis (Stagnaro-Green et al 1995). Length of stay

7 Fasting prior to surgery can lead to hypoglycaemia. Type 2 diabetes increased risk of cardiovascular and renal complications, (Williams and Piccup). Prevent complications. NSF, Standard 8. Effective and safe guidelines needed for safe management of patient with diabetes undergoing g surgery.

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9 Perioperative assessment Poor adherence to guidelines. Inconsistencies in approach to diabetes care by nursing, medical and anaesthetic staff. Poor referral rates to diabete es team. Patients complaints and anxieties.

10 National Service Framework for Diabetes and the drive for Day Surgery highlighted need for patients with diabetes requiring individualised care dependant on their diabetes treatment and complications prior, during and after surgery.

11 Aud dit. Re-audit in 2003 of periopera ative care of people with diabetes found a poor adherence with local diabetes guidelines. Pre- assesment proforma, varying levels of nursing, medical and anaesthetic staff knowledge. No set process, fragmented service,

12 Au udit 59% of all staff recognised diabetes was a potential problem upon perioperative e assessment e however e few commented on presence or lack of complications of diabetes prior to surgery. 50% of all staff followed a pla an of perioperative management, however only 35% of these was the plan of management in line with local guidelines. 8% had any involvement from the diabetes team. 27.5% had follow up with reg gards to the diabetes team.

13 Proportion of different health care professionals recognised diabetes as a pote ential problem upon perioperative assessment Surgical Staff 77% Anaesthetic Staff 59% Nursing Staff 90% % 30% 84%

14 Proportion of different group ps of healthcare professionals who recorded a perioperative plan of management in 1995 and Surgical Staff 53% Anaethetic Staff 47% Nursing Staff % 31% 72%

15 What happe ened next? Results presented to consultan nts anaesthetists forum. Staff education not cascading down to appropriate staff. Small task force developed inc cluding Senior Nurse (Diabetes), Consultant Diabeteologist, Consultant Anaesthetist, Modern Matron for perioperative care. Concurrently discussions with surgery established: Lack of knowledge, inconsistencies in treatment. Check with anaesthetist, no consistency. pre assessment nurses for

16 Study day for pre-assessment nurses on diabetes. Reviewing types of diabetes, surgery. Agreed by trust, classed as a complications and impact on priority. Led to development of path hway for pre-assessment including: Initial assessment by pre-assessment nurses, Type of diabetes Methods of treatment Level of glycaemia (HBA1c) Presence of complications Ability to self care.

17 Impleme entation. Education of all staff. DSN led clinic Non-medical prescribing Informal feedback: Anaesthetists less referral ls and postponed operations. Pre-assessment nurses clear pathway to follow, no need to chase up anaesthetists. More confident in role, plan care for patients confidently. Patients- reduced length of stay. Insulin regimens prescribed, reduced anxietie es.

18 Path hway List admission : - Pre assessment. Diet controlled or on one oral agent do not need to refer. On 2 oral agents and HBA1c below 8.5% - do not need to refer. On insulin and HBA1c below 8.5% - do not need to refer. On insulin or more than 2 oral a gents and HBA1c above 8.5% - refer. If HBA1c above 8.5% - refer If bgl's predominantly above 11 or below 4mmols then refer to diabetes team.

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20 What next? Re audit. Procedures Minor operations Education

21 Current practice Review approximately patients per week. Very few cancelled, some po ostponed for 2 weeks to optimise control. Discussion with anaesthetists less cancelled operations. Within last 3 months 60 patients t increased medication. 20 patients commenced insulin. 6 patients started on Byetta. Anecdotal evidence from patients.

22 'The pathway ensures that people with diabetes who need an operation receive a care plan that fully reflects their needs.' Marie Digner Modern matron and Clinical Lead for pre-assessment Royal Bolton Hospital

23 Than nks to Marie Digner Modern Matr ron & Clinical Lead Abhijit Sinha Consultant Anaesthetist John Dean Consultant Dia abetologist Audit Team Pre-assessment Nurses.

24 Thank you for listening and any questions? nhs uk

25 Annual C onference 6 th Novem mber 2008 Royal Court Hotel, Coventry