Taking steps in the hospital to prevent diabetes-related readmissions

Despite the growth in scientific advances in management, diabetes continues to be a chronic disease plagued by frequent hospital readmissions. Patients with diabetes account for approximately 480,958 hospital in-patient stays per year with a 30-day readmission rate of 97,784, accounting for a 20.3% hospital readmission rate.

Given these statistics, it’s not surprising that reducing readmission rates for patients with diabetes has become an important goal for hospitals and healthcare providers. And, given the number of people who will be diagnosed with diabetes in the future, emphasis on that goal is only likely to increase. Consider that currently 26 million people in the United States (8.3% of the population) have diabetes, and another 7 million people have undiagnosed diabetes. Estimates indicate an additional 2 million people 20 years and older are diagnosed with diabetes each year. Finally, estimates of people at risk for diabetes or people with pre-diabetes are approximately 79 million.

As a nurse, you play a pivotal role in reducing readmission rates by participating in team initiatives related to patient education and self-management and by ensuring that preventing readmissions is addressed early during the hospital stay.

It takes a team

Preventing diabetes-related hospital readmissions takes a multidisciplinary team that includes registered nurses, nurse practitioners, physicians, physician assistants, registered dietitians, pharmacists, social workers, nursing assistants, and certified diabetes educators (CDEs). (See About certified diabetes educators.) The team helps educate patients, serves as a resource to staff, and collaborates with other healthcare providers.

About certified diabetes educators

Certified diabetes educators (CDE) focus on patient education and self-management. CDEs commonly work in hospital outpatient clinics, inpatient hospital settings, and in community practices; however, the American Association of Diabetic Educators (AADE) reports that CDEs are underutilized.

Even if fully utilized, because there are only about 18,000 CDEs in the United States, the bulk of the education will fall to other members of the healthcare team. Registered nurses, pharmacists, and other clinicians must be familiar with strategies for patient-centered care and diabetes self-management.

Nurses can partner with other members of the team to ensure patient needs are met. For example, pharmacists can provide a Diabetes Discharge Kit, an individualized kit that might include a home monitoring diary, educational materials, insulin materials if needed, and medication reconciliation information; social workers can coordinate home health care as needed and obtain prior authorization for supplies. Staff nurses can assess a patient’s skill and knowledge and provide instruction on diabetes management and complications.


Coordination of the interprofessional team by the primary care provider is important in discharge planning and preventing readmissions.

Start early

Actions to prevent readmission should begin when the patient is admitted to the hospital and reevaluated as patient care needs change. Early discharge planning is particularly important for high-risk patients such as those who:

  • have elevated glucose levels or poor glycemic control
  • have been newly diagnosed as having diabetes
  • are starting insulin therapy
  • have comorbidities
  • had a recent hospital admission for diabetes ketoacidosis (DKA) or hypoglycemia
  • have a readmission diagnosis of hypoglycemia or hyperglycemia.

The multidisciplinary team must evaluate preadmission factors that can affect patient needs during hospitalization and after discharge, including:

  • functional abilities or limitations
  • economic factors, such as lack of health insurance or inability to afford prescriptions
  • follow-up access to care (ensuring that patients have a primary care provider for follow up)
  • barriers to learning, such as language and motor skills
  • how well diabetes was controlled before hospital admission
  • readmission within 30 days of a previous admission
  • comorbid conditions
  • psychosocial evaluation primarily for depression, a common problem in patients with diabetes.

Admission assessments should include blood glucose and A1C. Glycemic control strategies should be implemented early in the hospital stay to attain optimal outcomes when ready for discharge. Early glycemic assessments are recommended because optimal control can take a number of days.

Referrals to the CDE should be made as early as possible, as they are an integral resource for learning needs, disease and medication education, resources, and transition to other levels of care and follow-up communication.

Education

When it comes to education, you and other team members can apply the standards for Diabetes Self Management Education (DSME), developed by the National Standards for Diabetes Self–Management Education and Support. The desired outcome is to help patients self-manage their diabetes by identifying appropriate goals and strategies.

The team should also follow the recommendation from the American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists (AACE) to conduct a needs assessment so the education plan can be individualized to the patient. Both the ADA and the AACE make recommendations as to what should be in the plan, including:

  • understanding the diagnosis of diabetes
  • recognition of symptoms such as hypoglycemia and hyperglycemia
  • information on constant eating patterns
  • medication management
  • incorporating physical activity into their daily plan
  • setting strategies to reach psychosocial and behavioral goals.

Planning discharge

Assessment of the patient’s knowledge, learning abilities, and educational needs must be evaluated before creating the discharge plan. Consider the following:

  • treatment plan at discharge
  • where and when for follow-up
  • remaining patient educational needs
  • education materials needed
  • durable medical equipment needed.

Don’t revert to the preadmission home management regimen without first assessing its effectiveness. Some guidelines recommend discontinuing all noninsulin diabetes therapies upon admission, but this can create confusion at discharge. Medication reconciliation procedures can avoid missing essential discharge medications. Ideally, the discharge plan should be implemented with the history of the preadmission and inpatient glycemic control and the competence of the patient.

Transition communication

It’s important to document the diagnosis of diabetes at discharge. Studies have shown a link between a failure to record the diabetic diagnosis and hospital readmission within 30 days. Documenting the diagnosis of diabetes safeguards that accurate attention is received during hospitalization and discharge.

Most diabetes care takes place in the outpatient setting, so the team needs to “hand off“ or refer the patient to the primary care provider. The ADA recommends keeping the outpatient care provider fully informed about the patient’s hospital stay. During the transition of care, information regarding the patient’s hospital stay and treatment plan must be communicated to the outpatient provider. Every effort should be made to ensure continuity of care once the patient is discharged. (See Discharge communication.)

Discharge communication

The ADA recommends that the following items be transmitted to the outpatient healthcare provider when planning the patient’s discharge:

  • primary and secondary diagnoses
  • diagnostic findings
  • hospitalization dates
  • summary of treatments during the hospital stay
  • discharge medications
  • patient/family instruction
  • any pending tests at discharge
  • referrals made
  • inpatient contact information.

Other activities to complete at discharge include:

  • verification of insurance coverage for discharge medications
  • confirm follow up appointments with the post discharge provider
  • facilitate outpatient appointments and educational referrals
  • referral to nutrition specialists if needed.

Achieving success

Diabetes is an epidemic with an enormous economic and health burden. A multidisciplinary team approach helps improve adherence and prevent or reduce hospital admissions.

Scott J. Saccomano is an assistant professor in the department of nursing at Herbert H. Lehman College in New York.

Selected references

American Association of Clinical Endocrinologists. AACE Inpatient Glycemic Control Resource Center. Challenges in Effective Discharge Planning for Hospitalized Patients With Diabetes. 2010. [Slide deck].

American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care. 2013;36(suppl 1):S11-S66.

American Diabetes Association. Position Statement, Hyperglycemic Crisis in Diabetes. Diabetes Care. 2008;27(suppl):S94-S102.

American Diabetes Association. Nutritional recommendations and interventions for diabetes. Diabetes Care. 2008;31(suppl 1):S61-S78.

American Diabetes Association. Executive summary: Standards of Medical Care in Diabetes – 2012. Diabetes Care. 2012;15(suppl 1):S4-S10.

Burke S, Sherr D, Lipman R. Partnering with diabetes educators to improve patient outcomes. Diabetes Metab Syndr Obes. 2014;7:45-53.

Centers for Disease Control and Prevention (CDC). National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: U.S. Department of Health and Human.

D’Souza J, Deshmukh DS, Schreiner B. BC-ADM: What’s in it for me and my career. Presented at: American Association of Diabetes Educators 2013 Annual Meeting.

Elixhauser A, Steiner C. Readmission to U.S. hospitals by diagnosis. Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Statistical Brief # 153, April 2013: 1-19.

Fisher L, Glasgow RE, Mullan JT, et al. Development of a brief diabetes distress instrument. Ann Fam Med. 2008;6(3):246-52.

Funnel M. The Diabetes, Attitudes, Wishes and Needs (DAWN) Study. Clinical Diabetes. 2006;24(4):154-155./p>

Funnell MM, Brown TL, Childs BP. National standards for diabetes self-management education. Diabetes Care. 2011;34(suppl 1):589-96.

Haas L, Maryniuk, M, Beck J, et al. National standards for diabetes self-management education and support. Diabetes Care. 2012;35(11):2393-401.

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Inzucchi SE, Berganstal RM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes: a patient centered
approach. Position paper of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2012;35(6)1367-79.

Martin A, Lipman R. The future of diabetes education: expanded opportunities and roles for diabetic education. Diabetes Educ. 2013;39(4):436-46.

Martin AL, Warren JP, Lipman RD. The landscape for diabetes education: results of the 2012 AADE National Diabetes Education Practice Survey. Diabetes Educ. 2013;39(5):614-22.

Moghissi ES, Korytkowski MT, DiNardo M, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care. 2009;32(6):1119-31.

Molinaro R. Diabetes cases on the rise: current diagnoses guidelines and research efforts for a cure, Medical Laboratory Observer. http://www.mlo-online.com/articles/201102. Accessed March 1, 2014.

Society of Hospital Medicine Glycemic Control Task Force. Workbook for Improvement. Improving Glycemic Control, Preventing Hypoglycemia and Optimizing Care of the Inpatient with Hypoglycemia and Diabetes. http://www.hospitalmedicine.org/AM/Template.cfm?Section=Home&Template=/CM/ContentDisplay.cfm&ContentID=11878. Accessed March 1, 2014:

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