The Pro‐Diab Melbourne Perioperative Study: A structured pre‐admission perioperative diabetes management plan to improve medication usage in elective surgery

Abstract

Background: Perioperative diabetes management has become increasingly complex; management is often inconsistent resulting in dysglycaemia and associated morbidity. Aim:To evaluate a structured pre-admission perioperative diabetes management plan (PDMP) for safe and appropriate recommendation, prescription and administration of diabetes medications in the perioperative period for people with diabetes undergoing elective, non-cardiac surgery.Methods: A multidisciplinary team developed the intervention, a structured PDMP (including diabetes medication reconciliation, management guide, individualised plan) to standardise optimal perioperative diabetes management. A single centre prospective pre-and post-intervention pilot study was performed, including all individuals with diabetes medications attending the pre-admissions clinic during two 4-month periods (February to May) in 2016 (control period) and 2017 (intervention period). The primary outcome was appropriate recommendation, prescription and administration of diabetes medications (including insulin), according to the PDMP, in the perioperative period. Secondary outcomes measures were glycaemia. Analysis was by intention to treat.Results: Control and intervention groups included 131 and 133 participants, respectively; they were well matched in clinical characteristics. The PDMP was completed correctly in 100 (75%) individuals in the intervention group. The appropriate use of diabetes medications increased from 30% in the control group to 71% in the intervention group (p < 0.001). Following the PDMP implementations, glycaemia improved in the overall perioperative period (8.7 ± 2.9 vs. 9.8 ± 3.3 mmol/L, p = 0.005) and at all time points (from admission and over entire hospital stay).

Longitudinal Digital Glucometric Benchmarking to Evaluate the Impact of Institutional Diabetes Care Initiatives in Adults With Diabetes Mellitus Over the 2016-2020 Period

“…Over the period since first establishing our institutional glucometric benchmark, we implemented a number of quality improvement changes aimed at optimizing glucose, including an inpatient diabetes nurse practitioner role in a proactive model of care (2016), 5 the Melbourne GAP (2016), 16 a peri-operative diabetes management plan (2017), 15 and hospital-wide NBGM (2019). 14 It is likely that these changes are at least in part responsible for the observed reduction in adverse glycemia, particularly as there is evidence for the individual components independently improving inpatient diabetes management.…”

“…[11][12][13] We have previously undertaken glucometric benchmarking at our institution. 10 In the years since, we have instituted a number of quality improvement changes in our inpatient glycemic management program including expansion of networked glucose monitoring technology to all inpatient wards of the hospital (enabling electronic-based glucometry) 14 ; implementation of peri-operative, 15 hyperglycemia and hypoglycemia management plans 16 ; and commencement of an inpatient diabetes nurse practitioner role (Figure 1). 5 However, as an improvement in hyperglycemia can come at the cost of increased hypoglycemia, 17 it is crucial to ensure that any systemic changes to inpatient glycemia management are producing the intended effect without significant adverse consequences.…”

Position statement: surgery and diabetes mellitus (Update 2023)

“…Sinnvollerweise soll die Nüchternphase so kurz wie möglich gehalten werden und wenn möglich die Operation als erster Punkt im Operationsplan stattfinden [ 6 , 28 , 57 ]. In der Pro-Diab Melbourne Studie war ein strukturierter perioperativer Diabetes Management Plan vor Aufnahme bei elektiven Eingriffen mit einem sicheren Umgang antihyperglykämer Medikation sowie verbesserter perioperativer Glykämie assoziiert [ 58 ].…”

“…Ziele der perioperativen Glukosekontrolle sind das strikte Vermeiden schwerer Hypoglykämien und ausgeprägter hyperglykämischer Stoffwechselentgleisungen, da diese mit erhöhter Komplikationsrate sowie längerer Krankenhausaufenthaltsdauer und gesteigerter Mortalität assoziiert sind [6,7,21,58,[68][69][70][71]. Eine stabile perioperative Einstellung des Blutzuckers ist relevant, um das perioperative Risiko zu minimieren [72,73].…”