prevention of admission & discharge planning dr andrew solomon dr chantal kong debbie...
TRANSCRIPT
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
?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
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