Introduction
This chapter aims to give key principles in ensuring patients with diabetes are discharged safely.
Effective and safe discharge planning for inpatients with diabetes improves patient experience and reduces readmission rates.
Discharge planning for inpatients with diabetes should begin at the time of admission to ensure a smooth, safe and well documented transition from hospital to discharge destination.
Where necessary involve the diabetes specialist team early in the pateint’s stay in hospital to allow early discharge planning.
All inpatients with diabetes, and/or their carers, should be involved in discharge planning.
A patient’s ability to manage their own treatment and any requirement for social support should be considered when planning a discharge.
Community support for diabetes management for patients unable to self-care, for whatever reason, should be arranged prior to discharge.
All medication, equipment and devices for diabetes management and monitoring, as appropriate to individual needs, must be available for the patient or carer at the time of discharge. These should be checked with the patient or carer prior to discharge.
All patients and their carers must be aware of their usual diabetes care provider following discharge as well as how to access emergency support for diabetes care if required.
On discharge all community services, including the GP, must be informed of changes made to the diabetes treatment and follow up plans.
Patients should be given a copy of their discharge summary which should include the name of the medication, dosage, frequency of dosing, device for injections, if appropriate, and follow-up arrangements post-discharge. Any agreed care plan should be included with the discharge summary.
Ensure the discharge planning for patients admitted primarily for active foot disease does not overlook their specific foot care needs and requirement for specialist MDT foot team follow-up if required.
CAUTION: Patients are sometimes prescribed PRN doses of a rapid acting insulin (eg, Novorapid) whilst in hospital to manage hyperglycaemia. This is NOT part of their usual diabetes management regime and should not be included in the discharge medication
10 key steps to safe and timely discharge
The table below details 10 key steps to safe and timely discharge (*adapted from: Ready to go, DH 2010). These steps are applicable to all patients including patients with diabetes.
| 1 | Start planning for discharge on admission. |
| 2 | Identify whether the patient has simple or complex discharge needs, involving the patient and carer in your decision. |
| 3 | Develop a clinical management plan for every patient within 24 hours of admission. |
| 4 | Co-ordinate the discharge or transfer of care process through effective leadership and handover of responsibilities at ward level. |
| 5 | Set an expected date of discharge (EDD) within 24–48 hours of admission, and discuss with the patient and carer. |
| 6 | Review the clinical management plan with the patient each day, or as appropriate, take any necessary action and update progress towards the discharge date. For patients with diabetes see Diabetes Daily Checklist (insert link or graphic from daily diabetes review chapter). |
| 7 | Involve patients and carers so that they can make informed decisions and choices that deliver a personalised care pathway and maximise their independence. |
| 8 | Plan discharges and transfers to take place over all seven days of the week to deliver continuity of care for the patient. |
| 9 | Use a discharge checklist 24–48 hours prior to transfer (refer to individual trust for local checklists). |
| 10 | Make and review EDD and decisions to discharge each day. |
Sick day rules and advice given to patients on discharge
On discharge patients should be advised to take their insulin or other medication as advised in the discharge letter. Where necessary the diabetes team will ensure patients are given appropriate information about what to do if they feel unwell following discharge (sick day rules). In general patients should be advised that blood glucose levels may be erratic initially following discharge and blood glucose testing may need to be undertaken more frequently (up to 4 times a day) where appropriate.
Sample advice (local guidance may vary):
Monitor your blood glucose if you have the equipment to do so – 4 times per day if possible.
You should test more frequently if you are unwell, nauseated or vomiting.
Your blood glucose may be higher than usual.
If you are feeling unwell (particularly if vomiting and unable to take food or medication) contact your usual diabetes team/GP surgery. If you have type 1 diabetes check your ketones and seek urgent advice if elevated.
If outside normal working hours contact the out of hours service
What should I do if I am unwell?
NEVER stop taking your insulin – illness usually increases your body’s need for insulin.
If you take an SGLT2 inhibitor tablet (dapgliflozin, canagliflozin, empagliflozin) stop immediately if unwell and seek urgent advice if blood glucose persistently elevated.
TEST your blood glucose level every 2 hours, day and night.
TEST your urine for ketones every time you go to the toilet or your blood ketones every 2 hours if have the equipment to do this.
DRINK at least 100ml water/sugar free fluid every hour – you must drink at least 2.5 litres per day during illness (approx. 5 pints!).
REST and avoid strenuous exercise as this may increase your blood glucose level during illness.
EAT as normally as you can. If you cannot eat or if you have a smaller appetite than normal, replace solid food during illness, with one of the following:
400ml milk
200ml carton fruit juice
150-200ml non-diet fizzy drink
1 scoop ice cream
When to seek urgent medical advice?
CONTINUOUS diarrhoea and vomiting, and/or high fever.
UNABLE to keep down food for 4 hours or more.
HIGH blood glucose levels with symptoms of illness (above 15mmol/L - you may need more
insulin).
KETONES at ++2 or +++3 in your urine or 1.5mmol/L blood ketones or more. (You may need more insulin). In this case, contact the person who normally looks after your diabetes immediately.
OUTSIDE NORMAL WORKING HOURS consult the local out of hours service or go to your local hospital A&E department.
Document: JBDS discharge Planning Document
*Department of Health (2010) Ready to go? Planning the Discharge and the Transfer of Patients from Hospital and Intermediate Care. The Stationery Office, London