How to manage a patient with hyperglycemia before discharge?

Managing a Patient with Blood Glucose of 350 Before Discharge

For a patient with a blood glucose of 350 mg/dL before discharge, implement a structured discharge plan including medication adjustment, education on diabetes self-management, and scheduling a follow-up appointment within 1-2 weeks to prevent complications and hospital readmission. 1

Immediate Pre-Discharge Assessment

1. Evaluate the cause of hyperglycemia:

   • Review inpatient glucose trends
   • Check HbA1c if not already done (indicates pre-admission control)
   • Determine if this is new-onset diabetes, poorly controlled known diabetes, or stress hyperglycemia

2. Medication management based on HbA1c:

   • HbA1c < 7.5-8%: Resume prehospitalization treatment regimen with possible adjustments 1
   • HbA1c 8-9%: Consider adding or adjusting basal insulin (50% of hospital basal dose) 1
   • HbA1c > 9%: Continue basal-bolus insulin regimen or seek diabetes specialist consultation 1

Discharge Medication Protocol

For patients with Type 1 Diabetes:

• Resume previous basal-bolus insulin regimen but adjust doses based on inpatient requirements 1
• Never discontinue basal insulin

For patients with Type 2 Diabetes:

• Previously on oral agents only:

  • If HbA1c < 8%: Resume previous medications if no contraindications
  • If HbA1c 8-9%: Resume oral agents plus add basal insulin at 50% of hospital dose 1
  • If HbA1c > 9% or glucose consistently >250 mg/dL: Consider basal-bolus insulin regimen 1

• Previously on insulin:

  • Continue insulin regimen with adjustments based on inpatient requirements
  • If transitioning from IV to subcutaneous insulin, give basal insulin 2 hours before stopping IV infusion 1

For stress hyperglycemia (no previous diabetes):

• Consider short-term follow-up without medications if clinical judgment suggests transient hyperglycemia

Essential Patient Education Before Discharge

Provide clear instructions on:

1. Blood glucose monitoring:

   • Target glucose ranges
   • Frequency of monitoring
   • When to call healthcare provider (e.g., persistent readings >300 mg/dL)

2. Medication management:

   • Proper insulin administration technique if applicable
   • Timing of medications
   • Dose adjustments if prescribed

3. Hypoglycemia recognition and treatment:

   • Symptoms (shakiness, confusion, sweating)
   • Treatment (15-15 rule: 15g carbohydrate, recheck in 15 minutes)

4. Sick day management 1

5. Nutrition guidance:

   • Consistent carbohydrate intake
   • Meal planning
   • Consider referral to registered dietitian

Follow-up Planning

• Schedule follow-up appointment before discharge to increase attendance likelihood 1
• For patients with hyperglycemia during hospitalization, schedule follow-up within 1-2 weeks 1
• For poorly controlled diabetes (HbA1c >9%), consider expedited endocrinology referral 1

Medication Reconciliation

• Cross-check home and hospital medications to ensure safety 1
• Provide clear written instructions on which medications to continue, discontinue, or adjust
• Ensure patient has access to prescribed medications before discharge

Special Considerations

• For elderly patients (≥80 years), consider less stringent glycemic targets (HbA1c <8%) to minimize hypoglycemia risk 2
• For patients with nephropathy or other complications, target HbA1c of 7-8% to balance glycemic control with hypoglycemia risk 2
• Avoid discharge with sliding scale insulin alone as the sole regimen 1

Documentation and Communication

• Transmit discharge summary to primary care provider as soon as possible 1
• Include clear information about:
  • Cause of hyperglycemia
  • Treatment changes made during hospitalization
  • Follow-up plan
  • Medication adjustments

By following this structured approach, you can effectively manage patients with hyperglycemia before discharge, reducing the risk of complications and readmission while ensuring continuity of care.