Pre Op MSK Diabetes Specialist Nurse


Patients with Diabetes who have suboptimal glycaemic control are at a significantly higher risk of complications following Orthopaedic surgery.1,2


HbA1c levels over 69 mM/L are associated with a two to three fold increase in post-operative joint infections which can lead to multiple revisions, lengthy duration of antibiotics, reduced mobility and have a huge impact on employment, leisure and family.1,2


Getting It Right First Time have piloted the Ipswich Perioperative Pathway for Patients with Diabetes model across 10 NHS trusts in England with significant improvements in patient safety with 71% reduction in diabetes-related harm or complications, reduced length of stay, better patient experience and improved staff knowledge.3,5


By identifying patients with suboptimal glycaemic control before or at the point of referral for hip and knee replacement surgery, we can give them the best possible opportunity to be optimised before their operation.  There is a specially funded Diabetes Specialist Nurse who we can refer patients to for optimisation before Orthopaedic surgery.  They will contact the patient, advise on medication optimisation and can remotely monitor BM monitors.  We will be notified of any recommended changes.  If the patient’s glycaemic control is optimised then deteriorates again, they can be re-referred.4


How To Refer

Email referral letter to diabetesspecialistnurses@nhs.netincluding a patient profile. 



Inclusion criteria

Patients needing a joint replacement with HbA1c > 69 taken in last 3 months


Exclusion criteria

HbA1c under 69

HbA1c over 69 and one of below

BMI 40 and on GLP-1 eg. exenatide, liraglutide 

Severe retinopathy

CKD Stage 5

Severely/very severely frail (Rockwood score 7-9) 


Patients with HbA1c > 69 who meet the exclusion criteria can be referred to Endocrinology stating Pre Optimisation Request by usual referral on eRS


The patient profile/referral needs the following on, most of which is on the profile already

Type of Diabetes 

HbA1C level within 3 months 

All current medications (dose/route) and medical devices used (pumps/flash monitor / CGM) 


Most recent blood pressure  


Presence and management of co-morbidities 

Type of Surgery and estimated waiting time (if known)


1. Alamanda VK, Springer BD.  The Prevention Of Infection: 12 Modifiable Risk Factors.  Bone Joint J 2019 Jan; 101-B1 (1 Supple A):3-9.

2. Lengeurran E et al.  Risk Factors Associated With Revision For Prosthetic Joint Infection Following Knee Replacement: An Observational Cohort Study From England And Wales.  The Lancet 01 2019 Jun; 19, 6, 589-600

3.Page E, Allen R, Wensley F, Rayman G.  Improving The Perioperative Pathway For Patients With Diabetes Undergoing Elective Surgery: The IP3D Project.  Diabetic Medicine; 37 (Suppl 1) 6-29

4. Veall A.  Clinical Guideline For The Diabetes Perioperative Pathway For The Musculoskeletal Service.  Royal Cornwall Hospitals NHS Trust, December 2021

5. Getting It Right First Time.  GIRFT Pilot Programme Leads To Better Outcomes For Patients With Diabetes Undergoing Surgery, 28 March 2022

GIRFT pilot programme leads to better outcomes for patients with diabetes undergoing surgery – Getting It Right First Time – GIRFT



Dr Rebecca Hopkins, GP and Primary Care Lead MSK Pathways

Amanda Veall, Lead Diabetes Specialist Nurse, Cornwall Partnership Foundation NHS Trust


Date                3 May 2022


Review Date   3 May 2023