Caroline Thomas

Summary: Introduction: Surgery in patients with diabetes mellitus is associated with increased morbidity and mortality compared with those who do not have diabetes mellitus. This is likely multifactorial and could be attributed to organisational issues; dysglycaemia; hospital‐acquired diabetic ketoacidosis; errors with insulin prescribing and administration; issues with fluids and electrolytes; and systemic and surgical site infections. There was a need to update guidance for the peri‐operative management of diabetes mellitus given improvements in our understanding, introduction of novel drugs and development of wearable technologies. Methods: This was a multidisciplinary consensus statement with a diverse authorship group, including diabetologists; anaesthetists; surgeons; pharmacists; surgical diabetes inpatient specialist nurses; and patients with lived experience. We undertook a directed literature search and a three‐round Delphi process to develop, refine and agree recommendations. Results: Following three rounds, 38 recommendations were included, spanning all phases of the peri‐operative pathway. Recommendations were made for organisations and general principles for the management of patients with diabetes, aiming to improve pathways, implement protocols and support training. We prioritise individualised care plans, encourage clinical judgement regarding proceeding with surgery with out‐of‐range HbA1c concentrations and recommend ensuring appropriate insulin regimens are prescribed and administered. We also provide guidance for capillary blood glucose and ketone monitoring and management; safe handovers of care; and multidisciplinary care plans for the peri‐operative use of wearables. Discussion: This consensus statement provides principles to be applied throughout the entire peri‐operative pathway by healthcare professionals, institutions and patients. It is hoped that the implementation of these key recommendations will improve experience and outcomes for patients with diabetes mellitus having surgery.

Summary: Acute pain remains a significant issue for inpatients, for example, 20–40% of surgical inpatients report severe pain in the first 24 postoperative hours. Simple pain rating scales are widely used but have limitations. National guidelines recommend incorporating functional assessment to guide individualised pain management, though how best to do this remains unclear. This quality improvement project aimed to enhance the assessment of acute pain in adult inpatients at Leeds Teaching Hospitals by introducing functional assessment alongside standard pain scoring. Applying the Model for Improvement and Plan–Do–Study–Act cycles, we prototyped a Leeds Functional Activity Score and evaluated its usability across three cycles. Once the methodology of assessing functional pain was prototyped (cycle one), 79 adult inpatients' pain was assessed using both Leeds Functional Activity Score and the Numeric Rating Scale (cycle two). We found pain intensity patterns did not always predict functional impact. Functional assessment enabled conversations with patients about the need to manage function rather than targeting a pain score. Cycle three involved evaluation by 37 ward staff, with 73% rating it as ‘easy’ or ‘very easy’ to use. This cycle helped us to identify training needs. This report demonstrates that implementing functional assessment alongside traditional pain scoring is feasible, well received by staff and provides clinically meaningful context to guide analgesia. The Leeds Functional Activity Score has now been integrated into the hospital's electronic systems, alongside supporting training videos and communications.

Some text in this abstract has been adapted from Krishna MT, Bhogal R, Ng BY, Kildonaviciute K, Jani YH, Williams I, et al. A multicentre observational study to investigate feasibility of a direct oral penicillin challenge in de-labelling ‘low risk’ patients with penicillin allergy by non-allergy healthcare professionals (SPACE study): Implications for healthcare systems. J Infect 2024;88:106116. https://doi.org/10.1016/j.jinf.2024.01.015. This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) license. See: https://creativecommons.org/licenses/by-nc-nd/4.0/. The text below includes minor additions and formatting changes to the original text. Background: One in five inpatients carries a penicillin allergy label. However, 90–95% of labels are incorrect. Penicillin allergy labels lead to increased risk for serious hospital infections and longer hospital stay and are associated with higher estimated healthcare costs. Penicillin allergy testing is onerous and requires a specialist. Routine inpatient testing is not available. Recent evidence suggests that a direct oral penicillin challenge delivered by non-allergy specialists is safe in ‘low risk’ patients, who are highly unlikely to be allergic based on history. Aims: To explore behaviour, attitudes and acceptability of patients, healthcare professionals and managers regarding a direct oral penicillin challenge in ‘low risk’ patients. To inform development of an implementation framework and determine potential cost-effectiveness. Methods: This study (1 May 2021–30 April 2023) involved delivery of direct oral penicillin challenge by non-allergy specialists across three clinical settings (medical/infectious diseases wards, presurgical and haematology-oncology units) at three hospitals. The study had three workstreams: Workstream 1: Screening for potential suitability. Patients were stratified into ‘low risk’ and ‘high risk’. ‘Low-risk’ patients underwent direct oral penicillin challenge. Workstream 2: One-to-one semistructured interviews with patients (N = 43) and focus group (N = 28) discussions with stakeholders. Workstream 3: Care pathway mapping, decision-analytic modelling and value of information analysis were carried out to determine potential cost-effectiveness of direct oral penicillin challenge. Results: One thousand and fifty-four of 2257 screened patients were eligible, 270 of 643 approached patients consented (42%). Two hundred and fifty-nine patients were risk-stratified (155 ‘low risk’; 104 ‘high risk’). Of the 155 ‘low risk’ patients, 126 underwent direct oral penicillin challenge, 122 (97%) were de-labelled with no serious allergic reactions and 43 patients were interviewed. Low-risk patients accepted their allergy labels, had limited knowledge of the adverse impact and most were keen to have their labels reviewed. Healthcare professionals demonstrated a risk-averse approach, although would engage in the intervention with training, resource availability and a governance framework in place. The total costs of the direct oral penicillin challenge pathway were higher than the costs of direct oral penicillin challenge alone (£940 vs. £98–288 per patient). There were minimal expected savings in antibiotic and hospital costs in the short term and potentially large healthcare cost savings over 5 years. Limitations: Relatively small sample size for direct oral penicillin challenge, poor conversion rate, particularly in acute settings, patients with limited English language proficiency could not be included and the study was not sufficiently powered and controlled to conduct a cost-effectiveness evaluation. Conclusions: This first multicentre United Kingdom study showed that non-allergy specialist-led direct oral penicillin challenge is feasible in secondary care. A high proportion of direct oral penicillin challenges were successful, with positive feedback from patients. Majority of screened patients did not progress through the study pathway. Going forward, a multipronged approach is needed to enhance equitability of direct oral penicillin challenge in routine practice. Follow-up mechanisms to consider the intervention during a clinically stable state and a governance framework for those lacking capacity to consent are needed. The cost of delivering a direct oral penicillin challenge pathway in its entirety is significantly higher than the costs of performing direct oral penicillin challenge per se. Future work: A randomised controlled trial with long-term follow-up is needed to determine the cost-effectiveness of direct oral penicillin challenge. Study registration: This study is registered as ISRCTN55524365. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR129069) and is published in full in Health and Social Care Delivery Research; Vol. 13, No. 9. See the NIHR Funding and Awards website for further award information.

Background Over 95% of penicillin allergy labels are inaccurate and may be addressed in low-risk patients using direct oral penicillin challenge (DPC). This study explored the behaviour, attitudes and acceptability of patients, healthcare professionals (HCPs) and managers of using DPC in low-risk patients. Methods Mixed-method, investigation involving patient interviews and staff focus groups at three NHS acute hospitals. Transcripts were coded using inductive and deductive thematic analysis informed by the Theoretical Domains Framework. Findings Analysis of 43 patient interviews and three focus groups (28 HCPs: clinicians and managers) highlighted themes of ‘knowledge’, ‘beliefs about capabilities and consequences’, ‘environmental context’, ‘resources’, ‘social influences’, ‘professional role and identity’, ‘behavioural regulation and reinforcement’ and a cross-cutting theme of digital systems. Overall, study participants supported the DPC intervention. Patients expressed reassurance about being in a monitored, hospital setting. HCPs acknowledged the need for robust governance structures for ensuring clarity of roles and responsibilities and confidence. Conclusion There were high levels of acceptability among patients and HCPs. HCPs recognised the importance of DPC. Complexities of penicillin allergy (de)labelling were highlighted, and issues of knowledge, risk, governance and workforce were identified as key determinants. These should be considered in future planning and adoption strategies for DPC.

Opioids are effective analgesics but can cause harm. Opioid stewardship is key to ensuring that opioids are used effectively and safely. There is no agreed set of quality indicators relating to the use of opioids perioperatively. This work is part of the Yorkshire Cancer Research Bowel Cancer Quality Improvement programme and aims to develop useful quality indicators for the improvement of care and patient outcomes at all stages of the perioperative journey.A rapid review was performed to identify original research and reviews in which quality indicators for perioperative opioid use are described. A data tool was developed to enable reliable and reproducible extraction of opioid quality indicators.A review of 628 abstracts and 118 full-text publications was undertaken. Opioid quality indicators were identified from 47 full-text publications. In total, 128 structure, process and outcome quality indicators were extracted. Duplicates were merged, with the final extraction of 24 discrete indicators. These indicators are based on five topics: patient education, clinician education, pre-operative optimization, procedure, and patient-specific prescribing and de-prescribing and opioid-related adverse drug events.The quality indicators are presented as a toolkit to contribute to practical opioid stewardship. Process indicators were most commonly identified and contribute most to quality improvement. Fewer quality indicators relating to intraoperative and immediate recovery stages of the patient journey were identified. An expert clinician panel will be convened to agree which of the quality indicators identified will be most valuable in our region for the management of patients undergoing surgery for bowel cancer.