Discharge Planning For Diabetics Should Begin at Admission

GRAPEVINE, TEX. – The time to start an effective diabetes discharge plan is the moment the hyperglycemic patient is admitted to the hospital.

"I’m making a plea for the idea that a successful transition from the hospital to home begins with patient admission," Dr. John MacIndoe said at the annual meeting of the Society of Hospital Medicine.

Getting a hemoglobin A_1C on every hyperglycemic patient is a critical part of the plan. "With this information, we have a crystal ball in our hands. Almost all of the decisions we need to make about glycemic control are based on that very important thing we should do on admission: Get the HbA_1c. That is a window into the 3 months prior to admission, telling you what the baseline glucose was before the patient became ill."

But even with the best clinical information, there’s no point in designing a diabetes discharge plan to which the patient can’t adhere because of financial or social barriers. "Identify patients with issues that will complicate their outpatient diabetes management, because what you send them home on has to work well for them."

Financial barriers (lack of health insurance or very high insurance deductibles) have become ever more common over the past few years, said Dr. MacIndoe of the HealthPartners Medical Group and Clinics in Minneapolis. Social barriers might include poor home support, difficulty with getting to the pharmacy or doctor’s office, and substance abuse problems that interfere with any kind of self-care.

"When you see these, it’s critical to get diabetes educators and social services involved [to] try to overcome those problems. Get the issues out on the table early and you have a much better shot at identifying the solution."

The baseline HbA_1c is a key piece of information in determining a patient’s diabetes status during the hospitalization. "This allows you to identify the patient with a history of diabetes, the patient who has prediabetes or undiagnosed diabetes, and the one who develops temporary hyperglycemia simply from stress related to their illness, either before or during hospitalization. Regardless of the etiology, they all need to be treated aggressively to get the blood sugar in that target range."

But as the acute illness subsides, so may the need for insulin. "During recovery, patients almost always need less, and sometimes they need none at all. Use that admission HbA_1c to predict predischarge and outpatient needs."

Dr. MacIndoe offered the following scenarios based on the admission HbA_1c:

• Below 5.7%. These patients "don’t have diabetes and don’t need insulin. So take them off any insulin and monitor for 24 hours, and send them home with nothing to worry about."

• 5.8%-6.5%. "This person has a high risk for diabetes, but should be able to get off insulin entirely. You should recommend lifestyle changes [such as exercising and losing weight], because the data suggest that over time these patients are likely to develop diabetes, and lifestyle changes can prevent or postpone that." The American Diabetes Association now recommends adding metformin to the regimen of a prediabetic patient if the patient is younger than 60 years and overweight, he said.

• 6.6%-6.9%. "This is a person with well-controlled diabetes. If newly diagnosed, this patient needs to learn how to improve his lifestyle to maintain this control. And obviously, if it is a patient with established diabetes, you should send them home on whatever regimen they came in on, because it’s working."

• 7%-10%. "A level like this at admission means that diabetes is not well-controlled. If this is a new diagnosis, I usually send the patient home on an oral agent that won’t cause hypoglycemia. If it’s a known diabetic patient, you have an opportunely to make a difference here by increasing their regimen, either with orals or with insulin."

• 10% or higher. "This is urgently uncontrolled diabetes. Even though we’re loathe to start insulin on an inpatient before discharge, this is one time we would." This situation often requires repeat conversations and connection with diabetes educators, Dr. MacIndoe added. "People are not really in the frame of mind to comprehend what this all means," when they’re admitted. "Get them to see the educator as soon as they can understand what’s going on."

But even the best discharge plan won’t help if the patient doesn’t follow though because of financial or social issues. "Don’t forget, they have to be able to afford it. If they can’t, they are not likely to tell you so. They just won’t get it filled and will probably find themselves back" in the emergency department.