Making Foot Surgery Safer for Patients with Diabetes Building a New Trust Pathway Patient Safety Briefing
The Newcastle Peri-operative Diabetes Pathway Launched 9 May 2016 Aims to join up peri-operative diabetes care
National Diabetes footcare profiles 2-15
Background NCEPOD 2014 - Lower Limb Amputation (LLA): Working Together Sub-optimal peri-operative management diabetes Poor glycaemic control Lack of specialist diabetes team input Medication errors Patient harm events Primary audit NUTH 2015
NCEPOD REAUDIT 2016 DIABETIC CARE IN VASCULAR PATIENTS UNDERGOING LOWER LIMB AMPUTATION Eliza Davison 1, Lauren Jones 2, Ahmad Abou-Salleh 3 Lucy Wales 2 1 Newcastle Medical School 2 Northern Vascular Centre 3 Newcastle Diabetes Centre
Primary Audit 2015
Standards Comparison Guidelines Standard Freeman 2015 Freeman 2016 Blood glucose should remain between 4 and 12 mmol/l, and not >12 on more than one occasion in 24 hours, during inpatient stay Diabetic patients should be reviewed BOTH pre and post operatively by a specialist diabetic team Medication errors in diabetic management 100% 63% 61% 100% 15% 20% 0% - 63% Patient harm events 0% 20% 33%
How safe are we now?... 66% no perioperative plan diabetes from PAC 40% who should have had a GKI in theatre did not 1 in 5 who got a GKI did not need one 25% did not get their blood glucose checked in theatre 50% had no handover of diabetes plan from recovery or ITU to the ward 165 hypoglycaemic episodes in vascular ward patients with nothing done to reduce them in 110 > 50% persistent hyperglycaemia left untreated
The Challenge Surgical patients with diabetes have higher mortality and morbidity rates and increased lengths of stay Improved diabetic care improves outcomes > 5000 patients with diabetes have surgery at NUTH per year. Who is responsible for their diabetes?
Hangers and Levers! Serious incidents Datix NADIA NCEPOD 2011 : attempts to implement surgical diabetes guidelines lacked teeth and impetus 2014: Clinical Director approaches me with proposal for SU2S. 2015: Formal SU2S Perioperative diabetes care group established Patient Safety Briefing
Sign-up to Safety SU2S National patient safety campaign 2015-2017 Reduce avoidable harm by 50% in the NHS Aims nationally to save 6000 lives per year 12 Acute trusts signed up Trust priority surgical safety Peri-operative diabetes care
Sign-up to Safety SU2S Five pledges 1. Put safety first We will commit to reduce avoidable harm in the NHS by half and make public the goals and plans we have developed locally. 2. Continually learn We will make our organisation more resilient to risks, by acting on the feedback of our patients and by constantly measuring and monitoring how safe our services are. 3. Honesty We will be transparent with people about our progress to tackle patient safety issues and support staff to be candid with patients and their families if something goes wrong. 4. Collaborate We will take a leading role in supporting local collaborative learning, so that improvements are made across all of the local services that patients use. 5. Support We will help people to understand why things go wrong and how to put them right. We will give our staff the time and support to improve and celebrate the progress.
Surgical matron (Urology) Ward staff nurse Consultant anaesthetists Consultant Vascular surgeon Medical Student DSNs Deputy Director Pharmacy ITU matron F2 junior doctor Clinical Director Consultant Diabetologist Clinical Governance Pre-assessment clinic matrons
Monthly meetings Shared drive for all resources and ammendments Project managed. Reporting to SU2S board
The Newcastle Peri-operative Diabetes Pathway
Individual patient planning PAC
Patient information
Diet/tablets good control
Insulin or poor control
Emergency Patients
New GKI prescription
THEATRE GLYCAEMIC CONTROL and Use of the Glucose Potassium Insulin (GKI) Infusion **FOR USE BY AN ANAESTHETIST IN THEATRE ONLY** PREOPERATIVE HYPERGLYCAEMIA A patient with hyperglycaemia on the ward preoperatively should be managed by using the perioperative diabetes protocols. If there is insufficient time to stabilise the blood glucose to 12 or under, it may be reasonable to proceed with surgery in the following circumstances: Blood glucose 12-20 despite + URGENT surgery + NO KETONES in urine = s/c actrapid bolus 12 units May proceed with surgery but requires ACTIVE intraoperative blood glucose management (as per protocol ) This is entirely at the discretion of the responsible consultant anaesthetist. INTRAOPERATIVE CARE Check blood glucose in anaesthetic room if it has not been done within 1 hour, and at least hourly throughout surgery. Insulin dependent diabetics MUST have a GKI or other insulin regime during surgery if they are missing more than 1 meal in total, even with a normal blood glucose. Without insulin, these patients will become highly catabolic and will have worse outcomes. If the GKI needs to be disconnected for transfer, this should be reconnected immediately as Actrapid is only active for 3 minutes when given IV. Consider adding an extension to the GKI. Use a GKI in tablet-controlled diabetics with blood glucose outside 4-12mmol range, or if they are likely to be fasted postoperatively. Avoid actrapid infusions unless blood glucose >15 in order to facilitate good control on transfer to recovery and prevent using patient substrate for energy rather than glucose infusion. POSTOPERATIVE CARE Any actrapid infusion must be changed to a GKI on admission to recovery. Blood glucose must be checked on admission to recovery and immediately prior to discharge to the ward. A written plan must be provided on the postoperative diabetic handover form. Always continue GKI until one hour after subcutaneous insulin or tablets are restarted, which should be once the patient is eating and drinking Use the patient s original subcutaneous insulin regime or oral diabetes medications. Dose adjustment may be required as per handover sheet.
Post-op transfer to surgical wards
Surgical ward management diabetes
Summary Changes PAC plans in notes for all elective admissions New theatre/recovery protocols Transfer of care forms on return to wards New ward guidelines for diabetes management hyperglycaemia/hypoglycaemia New emergency admission guidelines
Further Information New chapter Diabetes Handbook on intranet for peri-operative management of diabetes Diabetes Specialist Nurse Team helpline Drop in diabetes perioperative drop in sessions over 3 weeks. Unit based teaching. FAQs bulletin
Examples of FAQS I am anaesthetising a patient with diabetes can I use dexamethasone to reduce postoperative nausea and vomiting? Answer: Avoid when possible but not an absolute contraindication Further information: AAGBI guidance: use dexamethasone with caution in all patients with diabetes, due to the hyperglycaemia it can cause. If it s use is felt to outweigh the hyperglycaemic risk, the patient should have hourly blood glucose monitoring for at least 4 hours after it s administration. My patient has not had a GKI put up on the ward as per the protocol, but now has hyperglycaemia in theatre, what should I do? Answer: Give subcutaneous actrapid 10 units, wait 1 hour, if the blood sugar remains over 12 give a further 10 units actrapid and at the same time start a GKI as per theatre protocol. Further information: Hyperglycaemia should be acted on promptly. If the first dose of actrapid brings the blood glucose into the normal range, no further treatment is necessary. If the patient has reduced blood flow to the skin, consider whether an intravenous infusion of actrapid will be needed. Never bolus actrapid IV as the half life is only 3 minutes. FAQs about insulin pumps My patient has a continuous insulin pump at home and has been told to continue it, is that safe? Answer: Yes, for those missing only one meal Further information: Patients are only allowed to have insulin pumps if they have good understanding of their diabetes, it s important to know that these are usually highly motivated and knowledgeable patients who can be a good resource of information regarding their own diabetes. For short procedures, when the patient is missing only one meal, the pump can safely continue on basal rate while the patient fasts. They should not use boluses, which are usually used to help the patient remain stable at meal and snack times. If they unexpectedly are delayed, they should stop the pump and move to a GKI protocol. If the patient is having a major operation where their skin perfusion is likely to be affected (for example if they
Ongoing Quality improvement Take 5 Audit tool Insulin related Datix summaries National Audit outcomes
Time will tell Take 5 Audit : Quality improvement. Datix reporting NADIA NCEPOD A journey just beginning but hopefully now a shared vision
Time will tell Insulin is not Insulin s not my my problem! Insulin is everyone s problem! Can we make surgery safer for patients with diabetes?