When should I consider referring a patient with HHS to secondary care for further management?

Consider referring a patient with hyperosmolar hyperglycaemic state (HHS) to secondary care immediately for further management if they present with severe dehydration, altered level of consciousness, or any signs of shock. These clinical features indicate a need for urgent hospital assessment and intravenous fluid therapy, which cannot be safely managed in primary care.

Secondary care referral is also warranted if the patient requires intravenous fluid replacement, electrolyte monitoring, or if there is diagnostic uncertainty between HHS and diabetic ketoacidosis (DKA), as hospital facilities are needed for appropriate biochemical investigations and monitoring.

In summary, any patient with HHS showing significant clinical dehydration, neurological impairment, or metabolic disturbance should be urgently referred to secondary care for comprehensive management.

References: This approach aligns with the principles of managing severe dehydration and metabolic emergencies in diabetes, as outlined in UK guidelines on diabetes and dehydration management ¹,².