Page 199 - Hospital Authority Convention 2017

Parallel Sessions

PS14.3 Community Outreaching Services 14:30 Room 221

Building an Integrated Service Bundles to Keep Diabetes Out of Hospital
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1
Lo CW , Leung SH , Lee KY 1
1 Community Nursing Service, Kowloon East Cluster, Nursing Services Division, United Christian Hospital, Hong Kong HOSPITAL AUTHORITY CONVENTION 2017
2
Introduction
th
Diabetes is a major cause of morbidity and mortality in Hong Kong. It was the 10 commonest cause of deaths in Hong Kong
and caused 492 registered deaths (1.1% of all deaths) in 2015. Hospital Authority projected that diabetes patients will increase
by 29% between 2012 and 2017. In 2014/15, discharged patient referred to Community Nursing Service (CNS) for diabetic
care accounted for 30% of total new cases both in Kowloon East Cluster (KEC) and all clusters. Although diabetic medication
regime is optimised during hospitalisation, the blood glucose could be fluctuated when return to usual life activities. KEC
CNS collaborated with endocrinology physicians and diabetes nurses in Tseung Kwan O Hospital on a pilot of an integrated
care bundle to enhance discharge support to patients with complicated diabetes, aiming to keep them out of hospital, and
self-managed their own conditions in the community.
Objectives
(1) To extend the continuity of care for patients with diabetes from hospital to community; (2) to stabilise the metabolic
condition of patients with diabetes by empowering patients/caregivers on diabetes management; and (3) to strengthen
community support and minimise healthcare utilisation.

Methodology
Patients with recent admission due to acute metabolic complications of diabetes requiring intensive monitoring, treatment
adjustment, and empowerment for glycaemic control and compliance would be recruited to the programme. Recruitment
could be made by the diabetes nurses or by CNS from their own patient pool. Patients are supported with regular CNS visits,
immediate diabetes specialist consultation, fast track clinic and inpatient support if necessary.
Results
Sixteen patients were recruited. Home support by CNS ranged from 4 to 12 weeks during which patients were empowered
to manage own glycemic condition and resulted in significant drop in post 3 months HbA1c. Diabetes specialists had been
consulted via phone or ad hoc clinic for 13 times, while there was no emergency attendance or admission required.

Conclusions
Results shown that these bundles of service allows early assessment and intervention to maintain patient with complicated
diabetes condition in community, and living a better quality of life with self-managed disease. They also enable for step-down
and step-up care in a seamless support network to meet patients’ need. Wednesday, 17 May

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