Hyperglycemia in Young Adults With Types 1 and 2 Diabetes Seen in the Emergency Department: A Health Records Review

Predictors of 30-day recurrent emergency department visits for hyperglycemia in patients with types 1 and 2 diabetes: a population-based cohort study

OBJECTIVES

This study's aims were to describe the outcomes of patients with diabetes presenting with their first ED visit for hyperglycemia, and to identify predictors of recurrent ED visits for hyperglycemia.

METHODS

Using linked databases, we conducted a population-based cohort study of adult and pediatric patients with types 1 and 2 diabetes presenting with a first ED visit for hyperglycemia from April 2010 to March 2020 in Ontario, Canada. We determined the proportion of patients with a recurrent ED visit for hyperglycemia within 30 days of the index visit. Using multivariable regression analysis, we examined clinical and socioeconomic predictors for recurrent visits.

RESULTS

There were 779,632 patients with a first ED visit for hyperglycemia. Mean (SD) age was 64.3 (15.2) years; 47.7% were female. 11.0% had a recurrent visit for hyperglycemia within 30 days. Statistically significant predictors of a recurrent visit included: male sex, type 1 diabetes, regions with fewer visible minority groups and with less education or employment, higher hemoglobin A1C, more family physician or internist visits within the past year, being rostered to a family physician, previous ED visits in the past year, ED or hospitalization within the previous 14 days, access to homecare services, and previous hyperglycemia encounters in the past 5 years. Alcoholism and depression or anxiety were positive predictors for the 18-65 age group.

CONCLUSIONS

This population-level study identifies predictors of recurrent ED visits for hyperglycemia, including male sex, type 1 diabetes, regions with fewer visible minority groups and with less education or employment, higher hemoglobin A1C, higher previous healthcare system utilization (ED visits and hospitalization) for hyperglycemia, being rostered to a family physician, and access to homecare services. Knowledge of these predictors may be used to develop targeted interventions to improve patient outcomes and reduce healthcare system costs.

Experience of emergency department patients after a visit for hyperglycaemia: implications for communication and factors affecting adherence postdischarge

BACKGROUND

While studies have reported factors affecting adherence to diabetic care plans from a chronic disease perspective, no studies have addressed issues with post-discharge adherence facing patients with diabetes after an emergency department (ED) presentation for hyperglycaemia. This study's objectives were to describe patient perspectives on their experience during and after an ED visit for hyperglycaemia and to identify factors that influence postdischarge adherence.

METHODS

We conducted a qualitative description (QD) study of adult patients who had visited a Canadian ED for hyperglycaemia. Consistent with QD, purposive sampling was utilised, seeking diversity across age, gender and diabetes type. Participants took part in semistructured interviews and thematic analysis was used to identify and describe core themes. Frequent team meetings were held to review the analysis and to develop the final list of themes used to recode the data set. Analytic insights were tracked using reflective memos and an audit trail documented all steps and decisions.

RESULTS

22 patients with type 1 and 2 diabetes were interviewed from June to October 2019. Participants identified several factors that impacted their ability to adhere to discharge plans: communication of instructions, psychosocial factors (financial considerations, shame and guilt, stigma and mental health), access to follow-up care and paediatric to adult care transitions.

CONCLUSIONS

This study describes the patient experience with the communication of discharge instructions, as well as factors affecting adherence post-ED discharge for hyperglycaemia. Our findings suggest four strategies that could improve the patient experience, improve adherence to discharge plans and potentially decrease the frequency of recurrent ED visits for hyperglycaemia.

Intravenous insulin for the management of non-emergent hyperglycemia in the emergency department

PURPOSE

There is currently no consensus regarding the necessity of emergency department (ED) glucose reduction to manage hyperglycemia in patients presenting without a hyperglycemic emergency. Known consequences of intravenous (IV) insulin administration include hypoglycemia, hypokalemia, and increased ED length of stay. The primary objective of this study was to assess the impact of IV regular insulin on glucose reduction and ED length of stay in patients presenting to the ED with non-emergent hyperglycemia. Secondary objectives included the characterization of potential adverse events.

METHODS

This was a retrospective, observational study of patients ≥18 years who received IV regular insulin and were discharged from the ED at a large academic Trauma Center. Univariate and multivariable regression analyses were utilized to determine if an association existed between IV insulin administration and blood glucose as well as ED length of stay.

RESULTS

A total of 405 patients were included in the analysis. An insulin dose >5 units was associated with a greater reduction in blood glucose (difference = 37.4 mg/dL; p < .001) but no difference in ED length of stay relative to ≤5 units. Furthermore, 7.9% of patients developed hypokalemia and 0.4% developed hypoglycemia.

CONCLUSION

The use of >5 units of IV regular insulin for the management of isolated hyperglycemia in the ED was associated with a modest reduction in blood glucose and no difference in ED length of stay compared with those that received ≤5 units. However, use of IV insulin for this purpose resulted in a 7.9% occurrence of hypokalemia.

Risk factors and prevention strategies for diabetic ketoacidosis in people with established type 1 diabetes

Diabetic ketoacidosis (DKA) is a serious acute complication of type 1 diabetes, which is receiving more attention given the increased DKA risk associated with SGLT inhibitors. Sociodemographic and modifiable risk factors were identified with strong evidence for an increased risk of DKA, including socioeconomic disadvantage, adolescent age (13-25 years), female sex, high HbA_1c, previous DKA, and psychiatric comorbidities (eg, eating disorders and depression). Possible prevention strategies, which include the identification of people at risk based on non-modifiable sociodemographic risk factors, are proposed. As a second risk mitigation strategy, structured diabetes self-management education that addresses modifiable risk factors can be used. Evidence has found that structured education leads to reduced DKA rates. Knowledge of these risk factors and potent risk mitigation strategies are important to identify subgroups of people with an elevated DKA risk. This knowledge should also be used when adjunct therapy options with an increased DKA risk are considered. Prevention of DKA in people with type 1 diabetes is an important clinical task, which should also be addressed when SGLT inhibitors are part of therapy.

Risk Factors for Adverse Outcomes in Adult and Pediatric Patients With Hyperglycemia Presenting to the Emergency Department: A Systematic Review

Hyperglycemia is a significant cause of morbidity and mortality, often resulting in adverse outcomes. This review aimed to identify predictors of adverse outcomes, such as repeated hospital visits, hospitalization or death, in patients presenting to the emergency department (ED) with hyperglycemia. Electronic searches of Medline and EMBASE were conducted for studies in English of patients presenting to the ED with hyperglycemia. Both adult and pediatric populations were included, with and without diabetes. Two reviewers independently screened all titles and abstracts for relevance. If consensus was not reached, full-length manuscripts were reviewed. For discrepancies, a third reviewer was consulted. Study quality was assessed using the Newcastle-Ottawa Quality Assessment Scale. Study- and patient-specific data were extracted and presented descriptively. Eight observational studies were reviewed; they included a total of 96,970 patients. Predictors of adverse outcomes included age, lowest income quintile, urban dwellers, presence of comorbidities, coexisting hyperlactatemia, having a family physician, elevated serum creatinine level, diabetes managed with insulin, sentinel visit for hyperglycemia in the past month, and high blood glucose level measured in the ED. Conflicting evidence was found for whether known history of diabetes was associated with risk. Factors associated with favourable outcomes included systolic blood pressure of 90 to 150 mmHg and tachycardia. This systematic review found 12 factors associated with adverse outcomes, and 2 factors associated with more favourable outcomes in patients presenting to the ED with hyperglycemia. These factors should be considered for easier identification of patients at higher risk for adverse outcomes to guide management and follow up.