Diabetes discharge checklist

A 55 year old business executive is being discharged from the hospital after a brief admission for cellulitis.  His only PMH is HTN and obesity.  During his stay, his casual serum glucoses were found to be in the high 200s mg/dL and a hemoglobin A1C resulted at 11.6%.  What should be done at the inpatient to outpatient transition to address his diabetes?

Diabetes Discharge Checklist 

    Does your patient have an A1C result recorded in the last 3 months?

    Does your patient have prescription insurance?

o  If not, consider cost-effective medications – eg. generic vs. brand, Novolin/Humalin vs. Lantus (actually, consider cost even if they do have it)

    Does your patient have a glucose meter?

o  Has your patient been taught how to use the meter?

o  Glucose goals:

-2016 ADA goals discussed here

o  Prescriptions for test strips and lancets?  (See Below)

§  Also consider cost – eg. generic (eg. TRUEtest) vs. brand (eg. Bayer, FreeStyle, OneTouch)

   Does your patient have an oral medication prescription?

o  Has he/she been taught how/when to take the medication?

o  Has hypoglycemia identification and management instruction been given?

   Does your patient have an insulin prescription? (See Below)

o  Can patient self inject?  Has a nurse/pharmacist observed the technique?

o  Has hypoglycemia identification and management instruction been given?

   If your patient was admitted for hypoglycemia, does he/she also need a prescription for a glucagon emergency kit? (See Below)

o  Has family been taught how to use it?                                                    

   Does your patient have an appointment for outpatient follow-up?

   Does your patient need home care follow-up?

   Has your diabetes self management education been documented?

How to write prescriptions for: Pens & vials

Pens (not all inclusive)	Prescription	Notes
Insulin glargine (Lantus)	Lantus Solostar Pen Inject    #   units Sub-Q q___ Disp 3mL x 5 pens	Product availability for pens: ·      Each box contains 5 pens ·      Each pen contains 3mL ·      Each 1mL (or cc) = 100 units insulin (a few exceptions exist for pens not mentioned here) ·         One pen = 300 units ·         One box = 1500 units ·      For doses up to 50 units daily, one box of pens will last one month (1500 units @ 50units/day = 30 days supply) Other notes: ·      Be sure to provide appropriate # pens for one month’s supply o    Pharmacist will only dispense whole boxes (multiples of 5 pens) ·      Pen expiration dates vary so consult product insert ·      All pens need pen needles (see chart below) ·      Not all insurances cover pens. Confirm that pens are covered by patient’s insurance before prescribing
Insulin detemir (Levemir)	Levemir Flexpen Inject   #   units Sub-Q q____ Disp 3mL x 5 pens
Insulin NPH	Humulin N Pen Inject   #   units Sub-Q q____ Disp 3 mL x 5 pens
Insulin aspart (Novolog)	Novolog Flexpen Inject   #   units Sub-Q 10-15 min before meals Disp 3mL x 5 pens
Insulin lispro (Humalog)	Humalog Kwikpen Inject   #   units Sub-Q 10-15 min before meals Disp 3mL x 5 pens
Insulin glulisine (Apidra)	Apidra Solostar Pen Inject   #   units Sub-Q 10-15 min before meals Disp 3mL x 5 pens
Mixed insulin	Humalog Mix 75/25 Pen Humulin 70/30 Pen Novolog Mix 70/30 Flexpen Inject   #   units Sub-Q BID (before breakfast and dinner) Disp 3 mL x 5 pens
Vials	Prescription	Notes
Insulin (type)	Insulin  (type)  100units/mL Inject   #   units Sub-Q q___ Disp   #   vials	·      Each 10mL vial holds 1000 units ·      For doses up to 35units/day one vial will last 28days ·      Vial expiration dates vary so consult product insert ·      Ensure patient has prescription for enough syringes

How to write prescriptions for: Insulin & other supplies

Item	Prescription	Sizes available	Notes
Syringes (for insulin vials)	Insulin syringe,  (size)  cc Use as directed   #   times daily Disp   #   boxes	·      3/10 cc syringe holds up to 30 units ·      ½ cc syringe holds up to 50 units ·      1 cc syringe holds up to 100 units	·         Order the smallest syringes for most accurate dosing ·         Come in boxes of 100 ·         Use one syringe per injection
Pen needles (for insulin pens)	BD Nano pen needles, 4mm Use as directed   #   times daily Disp   #   boxes	·      Other BD pen needles: Mini = 5mm Short  = 8mm	·      Come in boxes of 100 ·      Fit all types of pens ·      Use one needle per injection
Alcohol swabs	Alcohol Swab Pads Use as directed Disp   #   boxes		·      Come in boxes of 100 or 200
Glucagon	Glucagon  emergency kit Use as directed Disp # 2 (two)		·      Insurance may only cover 1 per yr (or less) ·      Same brand as strips
Lancets	Lancets Test blood sugar   #   times daily Disp    #   boxes		·      Most come in boxes of 100 or 150
Test strips	Glucose test strips  [Specify Brand] Test blood sugar   #   times daily Disp   #   strips or   #   boxes		·      Same brand as meter ·      Most strips come in multiples of 50
Glucometer	Glucose meter Dispense one and use as directed		·      Pharmacist can process various meters ·      All insurance companies have different formularies

Back to the patient

This patient’s new diabetes diagnosis and the significant elevation of his glucose means that numerous things need to happen at this time.  First, assessing his ability to pay for and understand how to take/use medications needs to be done.  As a business executive, he likely has medication insurance coverage and the capacity to understand testing and medication use instructions.  With an A1C of 11.6%, an insulin regimen is likely going to be needed and therefore testing supplies will also need to be ordered.  Discharge prescriptions should include a glucose meter, insulin(s) (probably pens for ease of use), pen needles, test strips, lancets, and alcohol swabs (just for when injecting, not testing).  He should also get training on how to use these all before he leaves and a scheduled follow-up appointment.

References:

American Diabetes Association.  Standards of medical care in diabetes – 2016.  Diabetes Care  2016;39(Suppl. 1):S1-112.

photo by heather aitken