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The challenge:

Having successfully reduced the length of stay of non-elective inpatients at Derriford Hospital, the diabetes team wanted to achieve similar success with elective patients and increase the number being treated as day cases. With as many as 20% of beds occupied by people with diabetes and 50% of hospital beds given over to elective patients the team saw that much could be done to improve care and save money.

The aim:

The ultimate aim of the project was to increase the number of people with diabetes, undergoing an elective procedure, being treated as day cases rather than inpatients. To achieve this aim, the team set out to provide diabetes expertise at as early a stage as possible in the elective care pathway; to improve the institutional plans for managing an individual with diabetes planning an elective procedure; to provide a troubleshooting role when problems arose, and to facilitate early discharge by providing close outpatient supervision after the procedure.

What did they do?

Funding for additional an diabetes specialist nurse post and a healthcare assistant post was secured. These new members of staff, along with the exisiting diabetes team, worked closely with the surgical, anaesthetic and medical teams involved in elective admissions. The newly expanded team split their work into four key areas:

1. Surgical pre-assessment – ensuring patients with glucose control problems and other complex needs were identified and referred to the specialist diabetes team pre-op.
2. Admission planning – plans and pathways were developed for common insulin and oral hypoglycaemic regimens and for different times of day of surgery and expected lengths of fast. Patient with complex needs had specific plans drawn up. Plans were communicated to pre-op staff, and the diabetes team were on hand every day to deal with problems and to help to avoid the overuse of intravenous insulin infusions.
3. Post operative care – The specialist team carried out daily reviews of relevant wards to identify and manage common post operartive problems, such as lack of appitite and postoperative insulin resistance and to oversee adjustment of diabetes treatment, the stopping of intravenous insulin regimens and restarting subcutaneous regimens.
4. Discharge – To support timely discharge, patients were given contact details for a diabetes specialist and, where needed, follow up clinic visits or telephone consultations were arranged.

What happened?

During the first year of the project, the total number of people with diabetes discharged on the same day as the procedure increased from 1080 to 1456. For the total hospital population the total number increased from 16, 329 to 18,579. This represented an increase of 34.8% for diabetes compared to 13.7% for the total hospital population.