ABSTRACT
Diabetes affects around 15% of surgical patients and is associated with significant morbidity [1]. Poor peri-operative glycaemic control can result in longer hospital stays, up to 50% increased mortality and adverse postoperative outcomes including wound infection [1, 2]. Therefore, it is important to ensure diabetic peri-operative care is optimal, and as noted, in recent years, there is room for improvement. Methods A retrospective re-audit of electronic patient records was conducted to determine if peri-operative diabetic management was in line with local and national guidelines. We included all diabetic adults undergoing emergency or elective surgery, excluding obstetrics, in January 2022 at Watford General Hospital. Results Forty-seven of 618 (7.6%) patients who underwent surgery in January 2022 were diabetic adults meeting inclusion criteria. Of these 87% had type 2 diabetes, 51% were male and 55% were elective cases. Median age was 67 years (interquartile range 58-78.5 years). The majority (49%) were designated ASA status 2. Five of 21 elective cases had a glycated haemoglobin (HbA1c) result of > 69 mmol.l-1. Median surgical start time for elective diabetic patients was midday with 38% of cases occurring after midday. Starvation time was more than one missed meal or 12 h in 49% of patients. Variable rate intravenous insulin infusions (VRIIIs) were indicated in 43% of patients but only 10% received VRIIIs. Peri-operative blood glucose was maintained between 6-10 mmol.l-1 in 34% patients, 70% had intra-operative glucose monitoring but none hourly. Ketone testing occurred in one of two patients where indicated. Dexamethasone was given to 51% of patients (five of those were diet-controlled). Discussion A larger sample size was obtained on re-audit with 47 patients vs. 10 patients in January 2021, likely due to effects of the COVID-19 pandemic on elective surgery. Blood glucose monitoring pre- and postoperatively in diabetic patients has remained at least 70% in both audit cycles, but use of VRIIIs fell from 60% to 20%. We presented the findings at a clinical governance meeting and discussion of the guidelines identified that multiple documents and significant text acted as barriers to implementation. Therefore, we designed a flowchart to improve compliance and placed this in theatres and pre-operative areas. We hope this initiative, in addition to local teaching, will improve peri-operative diabetic care. We plan to re-audit and consider implementing further changes if care remains suboptimal. (Figure Presented).