Diabetes is a common endocrine condition affecting 1.4 million people in the UK, with an estimated 1 million undiagnosed (Diabetes UK, 2004). Approximately 11000 people have diabetes in the Bolton area; and at any one time 15-20% of all hospital admissions are for people who have diabetes (Page and Hall, 1999). Surgery in people with diabetes is linked with an increased risk of surgical complications that can be reduced by professionals adhering to local and national guidelines (Department of Health, 2003). This article highlights the need for perioperative assessment of people with diabetes. Previous to the implementation of a care pathway, perioperative assessment had been done by junior medical staff, surgical ward nurses and anaesthetists on an ad hoc basis. A nurse-led pathway of assessment prior to admission and care planning for people with diabetes would ensure consistency and safety of care. This has resulted in an individualised perioperative care plan for the individual’s hospital stay at Royal Bolton Hospital.

People with diabetes are at an increased risk of developing perioperative complications and mortality (Rahman and Beattie, 2004). In response to physical stress, such as that caused by surgery, the neuro-endocrine system releases counter-regulatory hormones (cortisol, epinephrine and growth hormone), which can result in insulin resistance (Pickup and Williams, 1996). The physical stress of surgery can also lead to acute hyperglycaemia by the suppression of insulin release, which could cause diabetic ketoacidosis (DKA; Stagnaro-Green et al, 1995).

Raised blood glucose levels can lead to delayed wound healing and an increased risk of contracting postoperative infections (Rahman and Beattie, 2004). Optimum care that maintains stable blood glucose levels helps prevent the complications of surgery and reduce the inpatient’s length of stay (Ahmann, 2004). Raised blood glucose levels in people with diabetes can lead to a prolonged length of stay, up to 3 days longer than an individual without diabetes admitted for the same reason (Ahmann, 2004). People who have to fast prior to surgery can become hypoglycaemic (Pickup and Williams, 1996).

People with type 2 diabetes often have cardiovascular and renal problems which can complicate surgery (Pickup and Williams, 1996). Therefore, effective and simple guidelines for the safe management of the person with diabetes undergoing surgery are essential. Standard 8 of the National Service Framework (NSF) for diabetes addresses the need for such guidelines for the care of the person with diabetes during his or her stay in hospital (Department of Health, 2003).

Problems on wards

At Royal Bolton Hospital the treatment of diabetes on surgical wards used to be fragmented with little or no continuity in care. Current guidelines at the hospital recommend two sliding scales and intravenous fluid regimens for those undergoing a surgical procedure or investigation. Firstly, a glucose-potassium-insulin (GKI) sliding scale should be used for patients undergoing a short procedure who can eat within 6 hours postsurgery.

Secondly, a variable rate insulin regimen is used for people with diabetes who, following surgery, may not eat within 6 hours. This regimen has 50 units of insulin in 50 ml of normal saline solution in a syringe and 10% dextrose solution administered concurrently.

Although these guidelines were accessible, there was poor adherence to them by the multidisciplinary team. This highlighted confusion in terms of the appropriate regimen to use.

Previous to the implementation of preoperative assessment guidelines, there were frequent requests by nursing and medical staff for advice regarding the appropriate regimen to be used; more worryingly, the staff did not contact any member of the diabetes team, which resulted in inconsistencies in the treatment of diabetes during inpatients’ hospital stays. With the publication of the NSF for diabetes and a drive towards day surgery it has highlighted the need for patients with diabetes requiring individualised care dependent on their diabetes treatment and complications prior, during and after surgery (Healy and McWhinnie, 2003).

Audit

A retrospective re-audit of perioperative care of people with diabetes in 2002/2003 showed poor adherence with local diabetes guidelines and incomplete preoperative assessment of their care needs. This was despite the fact that 6 years previously a surgical audit was performed, the results of which led to the formulation and implementation of much needed guidelines.

The re-audit was conducted to establish the guidelines’ effectiveness. One hundred and nine case notes were retrieved with support from the clinical audit department. This included people with both type 1 and type 2 diabetes undergoing major and minor surgery.

Findings

Was diabetes recognised as a potential problem upon preoperative assessment?

Fifty-nine per cent of all staff recognised diabetes as a potential problem upon preoperative assessment; however, few commented on the presence or lack of complications of diabetes prior to surgery. Table 1 shows a breakdown by profession.