TABLE 3

Suggested Strategies to Improve LTC Facility Care Processes (3,19,43,4547)

ConcernSuggested Strategy
Inadequate evaluation on admission• Attempt to get complete medical records from referring sites, as well as from patients’ family.
• Ascertain whether patients have type 1 diabetes.
• Discuss and document goals of care with patients and/or family caregivers.
• Document any prior adverse events with medications and hypoglycemia unawareness.
• Assess patients’ cognition, mental health disorders, and support system.
• Review interdisciplinary care plan within 1 week of admission.
Inconsistent practitioner notification• Have standing facility orders or protocols for glucose monitoring and parameters for practitioner notification.
Hypoglycemia• Train all staff to recognize hypoglycemia.
• Institute nurse-driven treatment protocols, including use of nasal glucagon.
• Institute protocol for practitioner notification and prompt evaluation.
• Perform medication review and simplification or deintensification of the treatment regimen.
• Avoid sulfonylureas, if possible.
• Administer prandial insulin 15 minutes before or after meals, according to product recommendations.
• Stop prandial insulin if the mealtime dose is <10 units.
• Rotate insulin injection sites.
• Use shorter needle lengths (3–5 mm).
Persistence of SSI as the sole therapy regimen or for correction doses• Replace SSI with basal insulin (50–75% of the average daily requirement).
• Add 50–75% of the average insulin requirement used as SSI to existing dose of basal insulin.
• Use noninsulin agents or fixed-dose mealtime insulin for postprandial hyperglycemia.
• Increase the basal insulin dose by the average correction dose given at breakfast.
• Short-term SSI may still be needed for acute illness or irregular meal intake.
• Reduce the frequency of glucose checks.
• Use a simple scale such as “4 units of mealtime insulin if glucose is >300 mg/dL” if dementia or persistent irregular meal intake is a concern.
• Stop SSI as glucose levels stabilize.
High frequency of glucose monitoring in type 2 diabetes• Use oral agents when possible.
• Consider a weekly GLP-1 receptor agonist.
• Simplified the insulin regimen (basal insulin).
• Monitor twice daily to every 3 days depending on medical stability. (Increase monitoring if a patient is on steroids or has a severe infection.)
Foot and skin problems• Train first-line caregivers to perform foot assessment and report concerns to nursing.
• Perform foot inspections at scheduled visits and a comprehensive foot exam on admission and readmission.
• Promote weekly skin checks and reporting of concerns.
Unplanned transfers to acute care• Educate staff on the identification and treatment of hypoglycemia.
• Educate staff on the early detection of changes of condition (e.g., use of INTERACT tools).
• Perform clinical evaluation of patients if glucose levels increase or decrease acutely.
Medication errors• Perform appropriate reconciliation of medications on admission and after any care transition.
• Deprescribe or deintensify treatment regimens if patients’ A1C is below goal or if hypoglycemia occurs.
• Educate staff regarding medication brands, name confusion, and correct dosing and timing of medications.
  • Use caution in interpreting A1C; it can be falsely decreased in acute and chronic blood loss, hemolytic anemias, hemoglobin variants, and splenomegaly and falsely increased in iron, vitamin B12, and folate deficiency anemias, severe hypertriglyceridemia, and chronic alcohol and opioid consumption (18). INTERACT, Interventions to Reduce Acute Care Transfers (47).