Although many patients visit Emergency Departments (EDs) for hyperglycemia, there is no consensus on optimal care prior to discharge. Most of these patients present with moderate elevations of serum glucose without severe manifestations (i.e. diabetic ketoacidosis, hyperosmolar hyperglycemic state). The risk of discharging patients with an elevated glucose level is unknown.
Is glucose level at time of discharge from the ED associated with 7-day ED revisits or hospitalization?
All patients age 18 or older who had a glucose value of 400 mg/dL at any point during an ED encounter between January 1, 2010 and December 31, 2011, who were then discharged from the hospital
Occurrence of diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS), repeat ED visit for hyperglycemia, or hospitalization for any reason within 7 days of the initial ED encounter
A single center, cohort retrospective chart review
Patients with type 1 diabetes.
Patients with a chief complaint of hypoglycemia.
ED patients who were admitted to the hospital.
- 706 patient encounters identified and 566 patients with hyperglycemia were enrolled
- 71 patients (12.5%) were lost to follow up
- ED management of hyperglycemia varied
- 60% of patients received both IV fluid and subcutaneous insulin.
- 12% (70 patients) received neither.
- Mean arrival and discharge glucose were 491 and 334, respectively.
- Primary Outcome at 7 days
- Return ED visits: 13% (62/495)
- Hospitalization: 7% (36/495)
- DKA on revisit: 0.4% (2/495)
- HHS on revisit: 0%
- Iatrogenic Hypoglycemia during index visit: 2% (9/495)
- Statistical analysis using generalized estimation equations showed that an elevated discharge glucose level was not associated with increased risk of repeat ED visit or hospitalization within 7 days
- Similarly, drawing of a chemistry panel, administration of insulin, and IV fluid administration were not associated with an increased risk of 7-day repeat ED visit or hospitalization
- Well-designed statistical analysis that accounted for patients lost to follow up
- Although study was not blinded, primary outcome measures were recorded first
- Outcome measures were objective and patient-oriented
- Retrospective chart review has inherent limitations (confounders, incomplete charting, incomplete data capture)
- Study took place at a single center, and applicability to different populations is unclear
“ED discharge glucose in patients with moderate to severe hyperglycemia was not associated with 7-day outcomes of repeat ED visit for hyperglycemia or hospitalization. Attaining a specific glucose goal before discharge in patients with hyperglycemia may be less important than traditionally thought.”
Although this was a single-center retrospective chart review, it was well designed and provides good evidence that ED interventions to reduce glucose levels are not associated with decreased 7-day ED revisits or hospitalization. This study suggests that, among hyperglycemic patients expected to be discharged from the ED, management should focus on improving long-term glucose management and arranging good follow-up.
Potential Impact To Current Practice
In appropriate hyperglycemic patients who you plan to discharge from the ED, consider avoiding therapies to reduce glucose to an arbitrary value. Instead focus on long-term glucose management by ensuring patients have adequate medication and appropriate follow up.
Targeting a specific serum glucose in patients presenting to the ED with hyperglycemia unrelated to their visit is unlikely to benefit the patient.
S. Arora et al. A randomized, controlled trial of oral versus intravenous fluids for lowering blood glucose in emergency department patients with hyperglycemia. CJEM 2014; 16: 214–219 PMID: 24852584