Prevention of admission & Discharge Planning

DR ANDREW SOLOMON

DR CHANTAL KONG

DEBBIE STANISSTREE T

The Issue

Excess Use of Resources

• Excess costs

• Readmission

rates

What can happen when patients are sent to hospital as emergencies ?

• Maybe referred inappropriately by D/N, Care home , OOH etc

• Poor referral data / insufficient information re PMH/Medication

• Long trolley waits / pressure sores / incontinence

• Lack of hydration /nutrition

• Receiving Insulin – no food follow up

• ? Seen by Appropriate Clinician

• Access to usual medication

• Communication with Family, GP, D/N and Social care

• Carer or other responsibilities

• Long stay in A/E – then discharged very late via transport that – can be helpful or can leave elderly struggling to get inside house

What are the issues once patients are admitted to hospital?

• Receiving correct medication / correct diet/ timing of insulin and food

• Ward staff knowledge of diabetes and equipment

• Taking diabetes self management away from patient

• Complete change of environment

• Carers don’t know they are in hospital – police break in to find them not there

• Challenges in stopping / restarting district nurse / care arrangements

• Issues related to patient safety

• Intravenous insulin issues/sliding confusion

Frequent causes of emergency a/e referral or admission

Current Examples of admission:

• Hypoglycaemia

• Hyperglycaemia ? Urinary infection related

• Readmission following earlier discharge (diabetes specific)

• Terminal care

• Steroid induced hyperglycaemia

• Acute Foot

• Care home / D/N referrals

• but do they all need admission?

Recommendations for Prevention of Admission

• Pathways to follow for e.g. hypo/hyper/foot/sick days

• Clear individualised care plan with targets and management plan

• MDT teams-enabling access to timely specialist advice e.g. via Skype

• 7 day week services

• 24/7 HCP helpline

• 24/7 patient helpline (as per Paeds)

• Ambulatory care

• Hot clinics within the urgent care centre/ out of hours GP service

Prevention of Admission: Case Study 1

• Known Type 1, aged 22 years, lives at home with parents

• On Novorapid and Glargine. Was swapped to BD Levemir. Pt was encouraged to contact DSN with progress on new regime. After 10 days not heard!

• TC to pt. Off work, in bed, not well high temp ?flu. BGL 5-16, not tested for ketones.

• On questioning: BGL now 19, urine ketones 3+

• 2 hourly calls in to acute DSN throughout day, sick day rules advised, to see GP urgently

• By end of day, on amoxicillin from GP, ketone negative, BGL 7 mmol/l

Prevention of Admission: Case Study 2

• 86 Year old female on D/N caseload having twice daily bi-phasic insulin Humulin M3

• Hypoglycaemic at 2.8 mmol/l when D/N arrive 08.30

• D/N gives cereal and cup of tea with sugar (not following hypo flowchart guidance)

• Patient very slow to respond – D/N has 6 other patients to administer insulin to -so calls 999

• Taken to A/E and treated .

• Insulin changed to Lantus once daily – not guidance

• Three days later – patient sent back to hospital as hyperglycaemic on once daily insulin

• What went wrong /

•

Case study 3

• 86 year old started on Prednisolone 100mgs as in patient in for adverse reaction to chemo medication

• Gp called by family as “unwell”

• Gp checked Blood glucose – 20mmol/l – referred via spoc

• Insulin started same day – required very high doses insulin which was reduced in tandem with steroids over 8 months

• Never readmitted

Now we would like your help!

Split into 5-6 groups to discuss “What are the key elements of a pathway which would reduce inappropriate urgent admissions to A/E or AAU ?”

Suggestion cards on tables:

• Hypoglycaemia

• Hyperglycaemia /Diabetic keto acidosis

• Acute Foot

ONE PERSON TO FEEDBACK

Prevention of admission Feedback from groups

?Other recommendations for Prevention of Admission

• Pathways to follow for e.g. hypo/hyper/foot/sick days

• Clear individualised care plan with targets and management plan

• MDT teams-enabling access to timely specialist advice e.g. via Skype

• 7 day week services

• 24/7 HCP helpline

• 24/7 patient helpline (as per Paeds)

• Ambulatory care

• Hot clinics within the urgent care centre/ out of hours GP service

Prevention of Admission- Foot specific

• Foot Health Education for patients, carers and Health care professionals

• Early identification of change in foot status

• Appropriate antibiotic guidelines followed and for appropriate duration

• Appropriate early referral from Primary / Community to Acute or MDT foot clinic

• Annual reviews and foot risk stratification by trained HCP’s

• Commissioned referral pathways guidelines

However…

Not all admissions can be prevented, so how can we

plan a discharge?

Discharge Planning/ Facilitated early discharge

• Principles of discharge planning

• Starts on/pre admission: Prompt referral to the Diabetes specialist team

• Close collaboration between patient, GP, relatives/carers, MDT and DST,

• If referred for surgical procedure, GP to ensure optimisation if required

• Categorise discharges as ‘simple, complex or rapid’

• Communication with DNs, GP and/or HCC , CDSN imperative

Facilitated Early Discharge

• Ward nurses to enable patients to continue administering own injections so as not to de-skill

• Discharge checklist for use by ward staff

• If pre-admission diabetes medication stopped/altered whilst I/P ensure GP fully informed and GP /D/N advised

• Timely review by GP

• Good discharge letter including medication, follow up plans and education covered

• Appropriate equipment /medication to be sent home with patient especially if medication changed

• Avoid insulin changes if possible

• Early review post discharge to ensure plan working- avoid duplication of care

Discharge planning: Case study 1

• 53 year old admitted to acute with hypoglycaemia

• Treated and kept for 3-4 hours in A/E

• Sent back to N/H at 20 00 hrs –

• At 2200 , Nursing staff called DR as patient hyperglycaemic at 18mmol/l

• Dr advised stat Actrapid 5 units

• Patient found dead 0300

• Rebound hyperglycaemia should never be treated with extra insulin

Case study 2

• 73 year old on Humalog Mix 25 via Kwikpen discharged with Humalog cartridges at 2pm following stay in hospital for UTI

• Patient unable to use cartridges and called Gp

• Fortunately GP called DSN for advice on type of pen

• Patient had been on DSN caseload and knew she was on bi phasic insulin

• GP issued correct prescription – patient missed evening insulin

Case study 3

• Patient (no known relatives) who had been on D/N caseload as unable to self administer insulin was discharged after 2 week stay in hospital but D/N were not informed

• Taken home by transport

• D/N alerted a day later by GP following message from neighbour

• D/N attended to administer insulin but patient had no food in house as carers had not been reinstated either / flat cold etc

• D/N had to call ward to check insulin dosage – no one on duty who knew patient as she had changed wards etc

Now we would like your help!

Split into 5-6 groups to discuss “What are the key elements of a safe and Efficient discharge pathway?”

Suggestions:

• Improved Communication

• Discharge letter/tta’s

• Medication prior to discharge /timing with meals

• Insulin Safety/ Dealing with Vulnerable Groups

ONE PERSON TO FEEDBACK