Pathway for Adult Patients with Diabetes attending the Emergency Department (ED) with Hypoglycaemia

Transcription

1 Leicestershirediabetes Guidelines Pathway for Adult Patients with Diabetes attending the Emergency Department (ED) with Hypoglycaemia Patient attends ED Support available from Diabetes Specialist Nurses (DSN) to facilitate discharge bleep 4226 (Mon-Fri 9am-5pm) Patients who should always be referred to DSN: Patients who are pregnant Patients using a pump Examples of patient scenarios where input from DSN s may be beneficial in ED Hypo-unawareness Prolonged hypoglycaemia Patient/carer request Nursing/residential home resident Multiple attendances to ED with hypoglycaemia Patient assessed and if CBG < 4.0 mmol/l treat hypoglycaemia according to UHL guidelines* Clinical decision made by ED staff regarding discharge or admit Discharge Admit 1. ED clinical staff to complete Hypoglycaemia referral form / fax sheet and put hypo Sticker on patients notes 2. Inform patient that they will receive telephone follow up within 48 working hours 3. Give patient hypoglycaemia treatment leaflet and contact information sheet (both available on INsite*) 4. Receptionist to fax Hypoglycaemia Referral Form to (ICDS) 1. Admit to AMU if further medical attention required or observation for >12-24 hours 2. Bleep LRI DSN 4226 (Mon-Fri 9am to 5pm) or fax LRI DSN team on (258) 5573 Admit to EDU if require observation or if nursing home resident Dr Mark Williams & Dr Kath Higgins. Jan Re-approved by ED Consultant Team 1 June th Dec 2018 Review Date Extension Approved by Clinical Director Next Review Date 4th March 2019 Trust Ref: C108/2016 * Guideline available on INsite or Referrals made at weekends or bank holiday will be reviewed on the next working day

2 Treating hypoglycaemia: Blood glucose is less than 4mmol/L With or without symptoms Sweating Trembling Feeling of hunger Anxiety / Irritability Pale Palpitations Tingling of lips Difficulty in concentrating Vague / Confused Convulsions Coma Patient CONSCIOUS? If IV insulin in situ: stop infusion Fast Bleep Doctor Check Check: A B C D E & BM Patient ABLE to self help Patient UNABLE to self help but able to swallow ABLE to secure IV access UNABLE to secure IV access Review patient on each treatment Repeat cycle to a maximum of 3 times If patient deteriorates or does not respond to oral treatment consider 100ml/hr IV glucose 10% or 1mg Glucagon + i.m. Give Fast acting CHO either: 5-7 dextrose tablets OR Cold sweet drink e.g. Fruit juice ( mls) Original Lucozade (90-120mls) Administer: Wait 15 mins re-check blood glucose Dextrogel (1.5-2 tubes) or Consider 1mg + Glucogon i.m. Doctor to prescribe and administer: 150ml IV glucose 10% over minutes 75 mls 20% glucose over minutes Check BM in 10 minutes and repeat once if necessary Prescribe and administer: Immediate glucagon + injection 1mg I/M KEY + 1mg glucagon i.m. only given once * volume should be determined by clinical circumstances CBlood Glucose less than 4mmols? Give longer acting CHO either: Cereal / sandwiches / biscuits Next meal if ready DO NOT OMIT INSULIN INJECTION IF DUE Check blood glucose in mins Refer to DSN for Hypoglycaemia education Regular capillary blood glucose measurement next 24-48hours Patient responded Check blood glucose If BM remains <4 consider IV 10% glucose infusion 100ml/hr* or 1mg glucagon + i.m. Check blood glucose and full medical review to consider other causes of Coma e.g. SAH, cerebral oedema ADULT PATIENTS WHO ARE NIL BY MOUTH Adjust / review IV insulin infusion Treat with IV glucose as above When BM >4.0 commence 10% glucose infusion 100ml/hr* Refer to UHL managment of adult hypoglycaemia guidelines

3 Leicestershirediabetes Guidelines Hypoglycaemia Referral Form / Fax Sheet Date: D D M M Y Y Time: Patient Details Name: DOB: Hospital : Pt Contact : Location: Emergency Department: Majors Leicester Royal Infirmary (LRI) Ward Minors Leicester General Hospital (LGH) Ward EDU Glenfield Hospital (GGH) Ward Confirm patient attended episode of hypoglycaemia: (CBG<4.0 mmol/l) Diabetes Medication: (Tick as appropriate) Outcome: D D M M Y Y Tablets Insulin Insulin Pump or Other injectable therapy (e.g. Byetta /Victoza ) Patient s Addressograph Hypoglycaemia Referral form: Discharged from ED/EDU Fax to ICDS ( ) Admitted to ward Bleep LRI DSN 4226* or out of hrs fax LRI DSN team 5537 # Discharged from ward Fax to ICDS ( ) Hypoglycaemia Referral Form for Adults Attending ED Additional information: Is the patient pregnant? Form completed by: (please print full name) Name: Job title: te: *Diabetes team working hours 9-5pm Mon-Fri # Referrals made at weekends or bank Holiday will be reviewed on the next working day Designed by S..Jamal

4 Emergency Decisions Unit Pathway Hypoglycaemia Date Has lived in UK >1 year? Inclusion criteria Diabetic patient who presents to ED with an episode of hypoglycaemia Period of observation likely to be less than 12 hours Exclusion criteria Inter-current medical condition or illness that requires admission to AMU EWS >2 Patient s low glucose not responding to treatment Pregnancy Patient on insulin pump This pathway is for use for patients who are diabetic and present to the ED with hypoglycaemia, who need a period of observation. Patients with hypoglycaemia should be treated as per the UHL guideline, available on insite. A copy of the algorythm from this document can be found on the back of the ED hypoglycaemia pathway. Support in the management of these patients, to facilitate discharge, should be obtained from the Diabetes Specialist Nurses (DSN) on bleep 4226 (Mon- Fri, 9am-5pm). Form should be faxed as per checklist. Patients on insulin should have dose reduced by 20% or 4 units. Do not omit dose Review oral medication if patient is on a sulphonylurea (eg gliclazide) and reduce dose by 50% EDU Plan Management checklist All patients should have: Patent IV cannula Drug chart written, including own regular medication Hypoglycaemia Referral form / fax sheet completed. To be faxed by EDU staff to Plan documented on this sheet including expected period needed until discharge if well and observations / BM frequency Please tick here if patient suitable for nurse discharge from EDU, when seen by the DSN and note relevant aspects for this on the EDU Plan section of this form Tick Box On discharge All patients should have: Advice re recognition and treatment of hypoglycaemia Patient information leaflet on hypoglycaemia treatment and contact information sheet Planned & agreed by Referring doctor Doctor in Charge Nurse in charge Print names Signatures NB: Pathway Must be signed by both Doctor and Nurse in Charge Dr Mark Williams & Dr Kath Higgins. Jan Re-approved by ED Consultant Team 1 June th Dec 2018 Review Date Extension Approved by Clinical Director Next Review Date 4th March 2019 Trust Ref: C108/2016

5 Dear Patient You have been admitted to the accident and emergency department with a low blood sugar level (hypoglycaemia). You have received treatment for low blood sugar levels and the doctors are discharging you home. They will pass your contact details on the Intermediate Care Diabetes Service (ICDS). A member of the ICDS will contact you by telephone to talk to you about your diabetes on the next working day. However the ICDS team work Monday to Friday only. If you have been seen over the weekend or at a bank holiday they will contact you on the next working day. Please ensure the hospital staff have a up to date contact number for you on your discharge. Yours Faithfully Intermediate Care Diabetes Service