PAH Pre-surgical Diabetes Optimisation Service - 12 month experience

Overview

Initiative type

Framework

Status

Deliver

Published

June 2025

Summary

The Princess Alexandra Hospital (PAH) Pre-Surgical Diabetes Optimisation service brings together a dedicated multidisciplinary team of Endocrinologist, Diabetes Educator and Dietitian working with people with diabetes in the Pre-Admission Clinic.

Key dates

1 April 2024 -

Facility:  Princess Alexandra Hospital (PAH)

Partnerships

The PAH departments of endocrinology and diabetes, anaesthetics, surgery, and pharmacy

Aim

Our Multi Disciplinary Team (MDT) Service aims to identify and provide intensive short term expert clinical guidance to those with high-risk diabetes in the lead up to elective surgery to minimise diabetes related perioperative surgical complications.

Outcomes

  • Analysis of the activity, interventions and clinical impacts of the service 4/24 - 4/25
    • Referrals received 311
    • Individual patients reviewed 164
      • Episodes of care - total reviews 301 % new / review cases to see endocrinologist93/77%
    • % new / review cases to see diabetes educator 44/36%
    • % new /review cases to see dietitian 32/35%
    • Age 59.7 years, Female 32%, Aboriginal Torres Strait Islander5%, South Sea Island / Pacific 17.5%,
  • T2DM / T1DM 79% / 17%, % insulin 74%, Mean Hba1c prior to review 8.76%
  • Clinic Interventions (% with medication adjustments, % VLED, %initiated on insulin, % given CGM, mean Hba1c pre surgery) - data to be finalised
  • Perioperative outcomes (admission glucose, % perioperative hypo, DKA, surgical site infection, hospital acquired infection - data to be finalised

    • Background

    It is well recognised that people living with Diabetes, particularly those with elevated Hba1c pre-surgery(1) have an increased rate of peri-operative complications.  These complications including day of surgery cancellation due to unstable blood glucose levels (BGL), hypoglycaemia, hospital acquired infections, longer length of stay have negative implications for both patients and health services.  For this reason, national guidelines recommend elective surgery be delayed in the case of poorly controlled diabetes (Hba1c >9%)(2).

    People requiring elective surgery commonly have diabetes. 

    From April 2023 - April 2024 at PAH, 1766 unique patients with diabetes were admitted under surgical teams 2395 and underwent 1635 surgical procedures - emergency OR elective (unpublished data - MSH Diabetes Dashboard).

    Irrigation of wound (usually diabetes related foot infection), coronary artery bypass graft, amputation of toe, renal transplant, below knee and above knee amputations being amongst the most common surgical procedures performed in those with diabetes - all procedures with significant risk of wound infection, particularly if elevated BGL peri-operatively.

    The previous workflow at the PAH for people with poorly controlled diabetes would be to:
    1) Delay surgery until diabetes optimisation achieved through review in standard diabetes clinics OR
    2) Proceed with surgery with poorly controlled diabetes

    We sought to determine whether a Diabetes Speciality MDT could provide short notice, intensive intervention to improve glucose management without delaying surgeries and facilitate proactive linkage with the inpatient diabetes team to ensure optimal glucose in both the lead up and post-surgical phase.

Methods

The service had short notice - given just three weeks from notification of funding to 1st clinic date.  We therefore developed an initial clinic model and workflow with plan to utilise Plan-Do-Check-Adjust methodology to design, initiate and continually improve the service.

Plan:

  • Consultation with Perioperative Anaesthetic Service, Pre-Admission Clinic nursing and administration staff to confirm referral criteria, referral process and workflow to account for short notice patient referral and bookings.
  • Advertisement of the new service through with surgical teams at individual surgical department meetings.
  • Presentation at Surgical Grand Rounds on two occasions, PA Anaesthesia conference.

Do:

The clinic structure was designed as below.

  • Monday am: Dietitian with insulin adjustment qualifications: phone review for insulin adjustments, triage referrals, data entry
  • Thursday am: Endocrinologist, Dieitian, Diabetes Educator: Clinic review with 5 new and 2 review patients
  • Thursday pm: Endocrinologist: Clinic review for review patients, triage referrals, data entry

The twice a week service allows for immediate triage and short notice patient booking as well as intensive insulin adjustment.

The service was flexible with face-face and telehealth bookings given short notice and intensive follow up.  We used continuous glucose monitors where possible to facilitate transparent glucose monitoring.

We were able to see approximately 5 new patients a week and conduct 4 – 8 review patient consultations per week.

At the time of discharge from the pre-surgical service we followed the below standard procedure

  • Chart entry for final pre-surgical diabetes medication plan
  • Recommendations for management of hyper/hypoglycaemia on the day of surgery
  • Recommendations for re-commencement of diabetes medications post procedure
  • Clear recommendations for management of diabetes technology (CGM +- Insulin pump) during the peri-operative and post operative period.
  • Letter to GP with outline of changes made and recommendations for follow up

Check:

  • Feedback from surgical teams and pre-admission staff on referral process was sought.
  • Use of Redcap data base to create a standardised clinical note and also collect data for analysis.

Act:
Feedback from stakeholders let to adjustments in our model of care and workflow during the first 12 months with lead to the below interventions

  • Update the referral process to use an e-blue slip.
  • Development of Redcap database for note entry and data collection purposes
  • Clearer recommendations for intra-operative and post operative management

Discussion

    We consider the first 12 months of this new MDT service a success.  We received a large number of referrals and were able to see many patients at high risk of negative diabetes related outcomes in the peri-operative period.  Anecdotally we feel the interventions achieved significant risk reduction for many patients although analysis of these interventions continues.

    Factors that contributed to success

    • A high demand for this service as evidenced by large number of patients with diabetes having elective surgery at the Princess Alexandra Hospital and increasing complexity of diabetes management including use of diabetes technology and medications that are associated with perioperative risks including GLP-1RA and SGLT2i.
    • Consultation with and buy in from the perioperative anaesthetic, pharmacy and nursing services who recognise the importance and impact of improving peri-operative diabetes management.
    • A multi-disciplinary expert clinical team to provide evidence-based interventions supported by diabetes technology use as resources allowed.

    Strengths

    • High attendance rates for new referrals as patients with diabetes are motivated to reduce the risk of surgery being delayed or peri-operative complications.
    • Being situated within the pre-admission clinic allowed clear communication pathways for perioperative anaesthetic service and nursing staff to facilitate opportunistic reviews and coordinate simultaneous reviews to minimise appointment burden on patients.
    • We were able to identify many patients who needed but have no dedicated diabetes speciality oversight and ensure appropriate follow up post operatively to reduce future risk.
    • We were able to proactively link our inpatient diabetes service to ensure timely diabetes speciality reviews post-operatively to optimise diabetes-related outcomes in hospital.

    Limitations
    The limitations of the service centres around the referral process.

    Receiving referrals only a short time before (<2 weeks) prior to surgical booking date gives limited opportunity to assess, intervene and provide final recommendations.  We were unable to see a number of patients that would have benefited from our service due to restricted time to surgery.

    We continue to look for ways in which we can effective proactively identified high risk patients and coordinate review once waitlisted, rather than waiting until surgical date provided.

    We liaised with the PAH casemix team to create a weekly report of patients with history of diabetes who are on the surgical waitlist.

    We have requested upgrade of the Glucose Assessment for Inpatient (GAIN) dashboard through the QLD Diabetes Network and OCCIO to facilitate more effective use of the Pre-admitted patient view which may be useful in proactively identifying patients at high risk.

    We continue to liaise with our surgical colleagues to promote early referral at the time of surgical bookings.

    We feel that this model of care is highly valuable and beneficial for people living with diabetes who are undergoing elective surgery, the clinical staff caring for these patients during inpatient admission and for health services where in hospital diabetes complications are financially burdensome.

    This diabetes-specialty lead model of care is simple and could be utilised across metro south sites.  The improved use of clinical data to proactively identify the highest risk patients would improve patient identification and clinic efficiency.

References

1.Yu A, Truong Q, Whitfield K, Hale A, Taing MW, Barker N, et al. Impact of preoperative haemoglobin A(1c) levels on postoperative outcomes in adults undergoing major noncardiac surgery: A systematic review. Diabet Med. 2024:e15380.


2.Anaesthetists ADSaANZCo. ADS-ANZCA Perioperative Diabetes and Hyperglycaemia Guidelines (Adults). 2022.

Key contact

Dr Benjamin Sly

Senior Medical Officer - Endocrinologist

Metro South Hospital and Health Service

Email:  benjamin.sly@health.qld.gov.au

Last updated: June 2025

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