A GIRFT-led pilot programme has been successful in improving the care of patients with diabetes before, during and after surgery, according to an independent post-pilot evaluation.

Improvements in patient safety, fewer complications, less time spent in hospital and a better overall patient experience are among the benefits demonstrated as a result of the Improving the Perioperative Pathways of Patients with Diabetes (IP3D) programme.

GIRFT is now exploring avenues for the pilots to be expanded, to help reduce the length of stay for patients with diabetes and free more hospital beds, supporting the post-COVID NHS drive to cut waiting lists for routine operations.

Ten trusts* took part in the initial pilot and it there are now plans to roll it out to a further 20 trusts where GIRFT data shows there is an increased length of stay for people with diabetes undergoing surgery.

The GIRFT national report for diabetes, published in 2020, highlighted that up to 20% of all hospital beds in England are occupied by patients with diabetes, although most (92%) are admitted for other conditions and illnesses. Around 330,000 surgical procedures are carried out on patients with diabetes in the UK annually, and their length of stay (LoS) in hospital is on average three days longer than patients without diabetes (four days for those admitted as an emergency).

To help reduce complications and LoS, the GIRFT report recommended that all trusts should have clear, audited perioperative pathways for people with diabetes, as well as a perioperative diabetes team.

The IP3D programme was first established at Ipswich Hospital (part of the East Suffolk and North Essex NHS Foundation Trust), where it successfully improved the outcomes and experience of people with diabetes undergoing elective care.

In 2019, GIRFT began a project to replicate the Ipswich model and roll out IP3D into 10 pilot trusts to see whether similar improvements could be achieved. The project has been led by GIRFT joint clinical lead for diabetes, Professor Gerry Rayman MBE, and workstream delivery manager Emma Page. They will present and discuss the evaluation of the pilots at the Diabetes UK Professional Conference 2022 on 28 March, in a session on inpatient care.

Trusts taking part in the pilots each recruited a Perioperative Diabetes Specialist Nurse (PeriopDSN) to offer support and education to staff and people with diabetes undergoing surgery. Trusts also adopted a Diabetes Perioperative Passport, a booklet given to patients before surgery to help them prepare for admission to hospital. Trusts were supported by the GIRFT team to adapt and roll out the IP3D pathway.

Prof Rayman said: “It was important that trusts were able to adapt the IP3D pathway to their local needs, and we were keen to support that. It was pleasing to see a number of innovations emerge, including dedicated diabetes surgical study days, working with primary care to improve surgical referrals and, in one trust, establishing a diabetes perioperative dashboard.”

Successes from the pilots included:

• Significant improvements in patient safety: Overall, there was a 71% reduction in patients with diabetes who experienced diabetes-related harm or complications, from 14% to 4%. These can include hyper- and hypoglycaemic events, foot ulcers, diabetic ketoacidosis (DKA) and poor wound healing.
• Less time spent in hospital: Length of stay (LoS) for elective surgery inpatients with diabetes fell from an average of 5.1 to 4.2 days, with one trust seeing a 41% reduction. LoS for patients with diabetes who had day surgery fell from 0.93 to 0.39 days, while LoS for patients with diabetes admitted as an emergency fell by five days, from 12.6 to 7.4 days.
• A better experience for patients: In a post-pilot survey, patients with diabetes noted improvements in seven out of nine areas of their perioperative care, and many commented on the positive impact their PeriopDSN had on their stay.
• Improved staff knowledge: Knowledge improved considerably during the project and confidence increased, particularly in the area of hyperglycaemia management.

Discussions are now under way to expand the programme, potentially recruiting more PeriopDSNs and developing an intensive IP3D learning course and an emergency surgery IP3D pathway.

Emma Page said: “One of the best outcomes was the feedback from patients, who commented how they had seen an improvement in their care and what a difference the PeriopDSN had on their stay in hospital. The general feeling was that the patient experience was less stressful and ran more smoothly due to their presence, which is the most important outcome of all.”

*The 10 trusts which took part in the pilot were:

• Manchester University NHS Foundation Trust (NW region)
• Stockport NHS Foundation Trust (NW region)
• James Paget University Hospitals NHS Foundation Trust (EoE region)
• The Hillingdon Hospitals NHS Foundation Trust (London region)
• St George’s University Hospitals NHS Foundation Trust (London region)
• Royal United Hospitals Bath NHS Foundation Trust (SW region)
• University Hospitals of Leicester NHS Trust (Midlands region)
• Northampton General Hospital NHS Trust (Midlands region)
• Portsmouth Hospitals NHS Trust (SE region)
• Hull University Teaching Hospitals NHS Trust (NE region)