What is your discharge procedure process?
Discharge Procedure Processes question asked 4/15/21
Collaborative Responses:
We have on average 2-5 new onsets admitted each week. Our team has a “post-hospital class” with up to 5 families at a time. At this “post-hospital” class (currently on zoom, pre-CoVID was in-person), families review CHO counts with RD, review the basics of diabetes with the CDE, then have a breakout session with CDEs for personal glucose reviews. Typically families attend the post-hospital class 1-2 weeks after discharge then see their MD 1-2 weeks after that. We are spoiled and have RD available PRN during clinic for anyone who needs a review. The benefit of that is that the RDs can see anyone (they don’t have their separate schedule), but I don’t think families get as in-depth review/education as they do with a more formalized appointment with RD.
I do think the group-based classes are helpful when volume is larger and the material to review is similar. It is nice for families to bond over the shared experiences.
I hope this helps,
Jessica Schmitt, MD, Pediatric Endocrinology and Diabetes, University of Alabama at Birmingham
I was asked to reach out to let you know how we handle new diagnosed children/adolescents and their families when they are hospitalized.
I usually send one of my nurses from the pediatric endocrine office to the hospital to start education if the floor or ICU nurses have not started it yet.
The endocrinologist consults at the hospital first before I send over one of my nurses.
When they are discharged, the family will follow closely with our office for any additional education needs either by RN or RD.
We schedule them in 1 month after initial education with nursing and nutrition and then 3-4 months after that to meet with the endocrinologist.
I hope that helps.
Feel free to reach out for any additional comments, Peg
Margaret Pellizzari, MBA, MS, RN, CDE, CDTC, FAADE. Cohen Children’s Medical Center of NY
They call us daily for at least the first 2 weeks for insulin adjustment.
They are seen by our CDE or ARNP 3-7 days after discharge in person or via telemedicine depending on patient and family.
They are seen by MD 2- 6 weeks after discharge in person or via telemedicine depending on patient and family.
They are seen by RD in hospital and followup depends on individual needs ( 1-6 months)
They are seen by Psychology either in hospital or via telemedicine 1st week after discharge or both.
Hope this is what you needed.
Janine
Janine Sanchez, MD, Associate Professor of Pediatrics, Director, Pediatric Diabetes
Division of Pediatric Endocrinology, Miller School of Medicine University of Miami
For new onset pediatric patients at the Barabara Davis Center, we do outpatient education M-F and with less capacity on Saturdays (if we don’t have a good opportunity to push them to Monday by getting at least basal in each day over the weekend). If they’re hospitalized at our hospital, the physicians meet with them on the consult service, but not for any diabetes education.
This system has worked well for us for over a decade.
Day 1: MD and CDCES – approx. 4 hours
Day 2 (now via Zoom) RD and SW – approx. 3 hours
1 week (also by Zoom, about 1 week after dx) – 6-7 hours of group class with optional 30 min CGM intro (to get people on CGM asap)
When Day 1 and Day 2 were back to back in person, we asked families to stay with a friend or in a hotel in Denver. We have a small pot of money to help families who couldn’t afford the hotel.
G. Todd Alonso, MD, Associate Professor of Pediatrics, Barbara Davis Center for Childhood Diabetes
At UAB:
We schedule a post hospital review class 1 month after discharge. This is with 4-8 (covid and pre covid) families either in person or now via Zoom. At this class (type 1 and type 2 classes offered) our CDE does a review and nutrition and social work check in as well.
CDE will call the family 3-5 days after discharge to review glucoses and offer support or dose changes as necessary.
We have been faster than our clinic with follow up visits and can see them back in 2-4 weeks. In clinic they can see our multidisciplinary team. We are finding that seeing them in clinic is more cumbersome if that visit occurs BEFORE the class. In an ideal world families would go to the class before coming back to clinic. Covid has made our class sizes smaller so this is a 2020 phenomenon.
I hope that helps! –Mary Lauren Scott, MD
It’s hard. We may set up individual reviews with patients who need interpreters or who may not be ready for carb counting etc. Financially it’s a lot to do without reimbursement for many institutions. We trialed billing level 2 or 3 visits depending on ability to get two systems covered in “exam” vitals/skin for acanthosis may be adequate.
Glucose review by CDE was documented and labs from hospital (antibodies, thyroid levels, etc) are printed and distributed to each family by CDE to prevent HIPPAA breach. Our doc has a 10 minute presentation and can answer questions and describe lab findings. We may need to pull one or two families aside to discuss unexpected results from the hospital. It’s hard to coordinate and we are still exploring ways to make it work. –ML Scott, University of Alabama
At Texas Children’s Hospital, we schedule a CDCES+RD visit in ~2 weeks after discharged followed by either MD or NP visit in ~4 weeks after discharge for patients with new onset diabetes. These are all done in-person for us now.
I would be very interested to hear what you learn!
Warm regards,
Dan
Texas Children’s Hospital
We do most of our teaches out patient. Prior to Covid most kids were diagnosed before getting into DKA so we have the ED give them lantus; send them home to return to clinic the next day for teaching. Since Covid we have seen many more kids in DKA so they are spending time in the hospital and then getting discharged to us in clinic for teaching. We have seen a HUGE increase in our Type 2 diagnoses recently. We are on our 7th teach for the week which is a big jump for a “normal” week. Once we do the teach with an RD and CDE we send them home, the fellows make calls each day for about a week. They then return to clinic for an apt where they again meet provider, CDE, RD and MSW. If they want to go into our CGM remote monitoring program We send them home with supplies and set up a TH apt to do the CGM start, a week later they meet with our NP over TH for a CGM follow up and then a month after that return to clinic for a follow up After than it is every 3 months
If they do not want the CGM We see them at that 1 week apt and then again at a month and then every 3 months
I hope this is helpful We are exhausted from the increased numbers
Jeannine Leverenz MS, RN, CDE
Stanford Pediatrics
For pediatrics: The NPs and PAs have 4 blocked HODC slots (and the MD’s create slots in their schedules as they come up) for these patients and the educators go inpatient to provide education.
For adults: Our inpatient educator is scheduling the HODC appointments. We created 2 slots every Wednesday with the fellows and an attending for these patients to be seen. There are 20 slots per week that are HODC/urgent with the adult NPs and PAs.
Thanks,
Margie
SUNY
This is Blake Adams, I am the site coordinator at Le Bonheur Children’s Hospital in Memphis, TN. Our process for the discharge of our new onset Type 1 Diabetic from inpatient unit is as follows:
Patient is educated with survival skills by bedside nurse and RD while inpatient. The unit coordinator emails the Outpatient CDE’s to schedule the Day #2 and Day #3 education. Before patient is discharged they are given follow up dates for education in the outpatient clinic and are instructed to call On-call MD for the next 7 days (between 5-6pm) to report daily blood glucose.
If patient is diagnosed in the ED or at the PCP office and not admitted, the On-call MD is notified and the patient is then scheduled to complete Day #1 education in the outpatient clinic the following day. The patient is seen by MD and then the clinic nurse and RD complete Day 1 education. The family is instructed to call On-call MD for the next 7 days (between 5-6pm) to report daily blood glucose.
Day #1 education/ survival skills
Day #2 education- Advanced diabetes care- including Insulin to carb education and further carb counting education
Day #3 education- clinic visit with NP and insulin pen education, intro to CGM and reinforcement
Day#4 education- Diabetes basics complete and focus on review of basics, healthy coping, research and upcoming technology
Our families typically complete all 4 required days of education within 4 months of diagnosis.
Hope this helps!
Below are some notes I have kept on this topic from past collaboration. Also attached document with an approach to “day hospital” education NCH is piloting.
We were inspired by CCHMC, who has the most robust program functioning in this area. Thier new QI person is Amy Grant (Mary Jolly retired) – thanks, Don Buckingham
7/1/2019 Ashley
One of our diabetes educators is interested in how other sites conduct their outpatient new onset education. I know we have talked about new onset education in the past, but I wasn’t sure on the answers to her specific questions for each site (see below):
- How do you conduct outpatient new onset diabetes education?
- How much staff do you use?
- How is it provided after hours/weekends/holidays?
- How long are the education sessions?
Mary Jolly
At CCHMC, we have new onset education standardized and it is provided consistently to each patient whether he/she is an inpatient (High severity & acuity of illness) an observation patient (Moderate severity/acuity) or an outpatient in our diabetes day hospital (low or no severity/acuity). It is a 2-day education process teaching families survival skills from 7:30am-4pm each day. We provide education 6 days/week. Families are taught on Sundays & holidays only in rare cases. All CDEs rotate assignment for new onset education – there is no set staff.
7/23/2019 Jeannie Leverenz / Stanford
I am just catching up on emails after slew of new onsets and then vacation time Stanford has been doing new onsets as outpatients for quite some time. Because of the expense to stay in the area it has been done all in one day.
When a child is diagnosed if they are not in DKA and thus do not require hospitalization they are given a shot of lantus by the ED and then sent home to meet the diabetes team the next morning at Stanford If they are diagnosed on a Friday they get admitted.
The CDE meets with the family at 10am (supplies from out patient pharmacy in hand) We start with an intro about the difference between T1D and T2D and move through finger sticks, injections, etc. RD meet over lunch (while they eat lunch) to discuss carb counting; then after lunch the CDE is back on to discuss treatment of highs and lows and warp things up. The session usually ends about 4pm It is a LONG day for the family!!
We then usually have them come back in the next week for a new onset CGNM placement and a review of education topics There is a telehealth follow up for the CGM placement in the next week and then about a week after that they have a follow up apt with the provider. If all is going well we see them a month later and then move to every 3 months
Ryan
Similar here in KC.
Day 1 (in our main KC clinic)
- Basic pathophysiology
- T1D vs T2D
- Finger Sticks
- Insulin Administration
- Highs, Lows, Sick Day
- RD for Carb Counting
Between Day 1 and Day 2: CDE’s check in with family regularly by portal or phone call.
Day 2 (about 1-2 weeks later, in our main KC clinic)
- Review carb counting
- Introduce ISF
- Exercise
- Introduce Technologies
Day 3 (about 1 month later, at any of our clinic sites)
- Knowledge assessment
- Skills assessment
- Individualized/targeted education on areas of concern/question
Then onto q3 month visits after that.
9/10/2019 8:34 AM Kathryn/SUNY
Sorry for the delayed reply for SUNY in our peds population:
we teach blood glucose monitoring, hyperglycemia, hypoglycemia, glucagon, ketones, carbohydrate counting, insulin administration and other insulin information (storage), and safe needle disposal all in the first day (usually a 3 hour training).
Then a week later we have them come back and reinforce everything along with CGM if provider thinks they need it right away (usually in NY insurance has in the past made them wait until a little after diagnosis).
Don (Nationwide Children’s)
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