1. Prevention of admission & Discharge Planning DR ANDREW SOLOMON DR CHANTAL KONG DEBBIE STANISSTREE T

2. The Issue

3. Excess Use of Resources Excess costs Readmission rates

4. 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

5. 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

6. 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?

7. 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

8. 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

9. 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 /

10. 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

11. 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

13. Prevention of admission Feedback from groups

14. ?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

15. 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

16. However… Not all admissions can be prevented, so how can we plan a discharge?

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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