TRANSITIONING PATIENTS WITH DIABETES OUT OF EMERGENCY DEPARTMENTS: A PATH TOWARDS BETTER OUTCOMES AND LOWER COSTS?

Initiating Insulin in the Emergency Center and Urgent Care to Prevent Hospital Admission for Patients with Hyperglycemia: A Unique Insulin Starter Kit

BACKGROUND

Clinicians in the Emergency Center (EC) and Urgent Care (UC) can play a vital role in preventing hospital admissions and improving outcomes of patients with newly diagnosed diabetes or pre-existing diabetes who present with hyperglycemia and the need to initiate insulin.

METHODS

This article describes a unique EC/UC discharge insulin starter kit protocol with clinician instructions via an Electronic Medical Record (EMR) order set that includes: starting doses for insulin, a prescription for glucose monitoring supplies, and an emergent referral to diabetes education at International Diabetes Center. Patients receive insulin during the EC/UC visit and are provided an insulin pen to take home. Nurses from the EC or UC review and provide educational material on how to use an insulin pen, treating hypoglycemia and healthy eating. The Certified Diabetes Care and Education Specialist (CDCES) sees patients within 24-72 hours after the referral is placed.

RESULTS

Within our single healthcare system's EC and UC (multiple sites), the kit has enabled clinicians to metabolically stabilize patients and decrease the need for hospitalization without experiencing hypoglycemia. In the recent three years of use, of 42 patients given the insulin starter kit, there were only 2 patients with repeat EC/UC visits within the first six months (1 hyperglycemia and 1 hypoglycemia).

CONCLUSIONS

An insulin starter kit and EMR-based order set initiated in the EC/UC setting is a tool that can be used to improve the quality of care for people with newly diagnosed or pre-existing diabetes experiencing significant hyperglycemia.

Experience of emergency department patients after a visit for hyperglycaemia: implications for communication and factors affecting adherence postdischarge

BACKGROUND

While studies have reported factors affecting adherence to diabetic care plans from a chronic disease perspective, no studies have addressed issues with post-discharge adherence facing patients with diabetes after an emergency department (ED) presentation for hyperglycaemia. This study's objectives were to describe patient perspectives on their experience during and after an ED visit for hyperglycaemia and to identify factors that influence postdischarge adherence.

METHODS

We conducted a qualitative description (QD) study of adult patients who had visited a Canadian ED for hyperglycaemia. Consistent with QD, purposive sampling was utilised, seeking diversity across age, gender and diabetes type. Participants took part in semistructured interviews and thematic analysis was used to identify and describe core themes. Frequent team meetings were held to review the analysis and to develop the final list of themes used to recode the data set. Analytic insights were tracked using reflective memos and an audit trail documented all steps and decisions.

RESULTS

22 patients with type 1 and 2 diabetes were interviewed from June to October 2019. Participants identified several factors that impacted their ability to adhere to discharge plans: communication of instructions, psychosocial factors (financial considerations, shame and guilt, stigma and mental health), access to follow-up care and paediatric to adult care transitions.

CONCLUSIONS

This study describes the patient experience with the communication of discharge instructions, as well as factors affecting adherence post-ED discharge for hyperglycaemia. Our findings suggest four strategies that could improve the patient experience, improve adherence to discharge plans and potentially decrease the frequency of recurrent ED visits for hyperglycaemia.