Hypoglycaemic attacks treated by ambulance personnel with extended training

People with diabetes and ambulance staff perceptions of a booklet-based intervention for diabetic hypoglycaemia, "Hypos can strike twice": a mixed methods process evaluation

Background

Hypoglycaemia is a potentially serious condition, characterised by lower-than-normal blood glucose levels, common in people with diabetes (PWD). It can be prevented and self-managed if expert support, such as education on lifestyle and treatment, is provided. Our aim was to conduct a process evaluation to investigate how ambulance staff and PWD perceived the “Hypos can strike twice” booklet-based ambulance clinician intervention, including acceptability, understandability, usefulness, positive or negative effects, and facilitators or barriers to implementation.

Methods

We used an explanatory sequential design with a self-administered questionnaire study followed by interviews of people with diabetes and ambulance staff. We followed the Medical Research Council framework for process evaluations of complex interventions to guide data collection and analysis. Following descriptive analysis (PWD and staff surveys), exploratory factor analysis was conducted to identify staff questionnaire subscales and multiple regression models were fitted to identify demographic predictors of overall and subscale scores.

Results

113 ambulance staff members and 46 PWD completed the survey. We conducted interviews with four ambulance staff members and five PWD who had been attended by an ambulance for a hypoglycaemic event. Based on surveys and interviews, there were positive attitudes to the intervention from both ambulance staff and PWD. Although the intervention was not always implemented, most staff members and PWD found the booklet informative, easy to read and to use or explain. PWD who completed the survey reported that receiving the booklet reminded and/or encouraged them to test their blood glucose more often, adjust their diet, and have a discussion/check up with their diabetes consultant. Interviewed PWD felt that the booklet intervention would be more valuable to less experienced patients or those who cannot manage their diabetes well. Overall, participants felt that the intervention could be beneficial, but were uncertain about whether it might help prevent a second hypoglycaemic event and/or reduce the number of repeat ambulance attendances.

Conclusions

The ‘Hypos may strike twice’ intervention, which had demonstrable reductions in repeat attendances, was found to be feasible, acceptable to PWD and staff, prompting reported behaviour change and help-seeking from primary care.

Trial registration

Registered with ClinicalTrials.gov: NCT04243200 on 27 January 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00583-y.

Characteristics, Prehospital Management, and Outcomes in Patients Assessed for Hypoglycemia: Repeat Access to Prehospital or Emergency Care

BACKGROUND

In Ontario, Canada, there currently are no prehospital treat-and-release protocols and the safety of this practice remains unclear. We sought to describe the characteristics, management, and outcomes of patients with hypoglycemia treated by paramedics, and to determine the predictors of repeat access to prehospital or emergency department (ED) care within 72 hours of initial paramedic assessment.

METHODS

We performed a health record review of paramedic call reports and ED records over a 12-month period. We queried prehospital databases to identify cases, which included all adult patients (≥ 18 years) with a prehospital glucose reading of <72mg/dl (4.0mmol/L) and excluded terminally ill and cardiac arrest patients. We developed and piloted a standardized data collection tool and obtained consensus on all data definitions before initiation of data extraction by trained investigators. Data analyses include descriptive statistics with standard deviations, Chi-square, t-tests, and logistic regression with adjusted odds ratios (AdjOR).

RESULTS

There were 791 patients with the following characteristics: mean age 56.2, male 52.3%, known diabetic 61.6%, on insulin 46.1%, mean initial glucose 50.0 dl/mg (2.8 mmol/L), from home 56.3%. They were treated by an Advanced Care Paramedic 80.1%, received IV D50W 38.0%, IM glucagon 18.3%, PO complex carbs 26.6%, and accepted transport to hospital 69.4%. Of those transported, 134/556 (24.3%) were admitted and 9 (1.6%) died in the ED. Overall, 43 patients (5.4%) had repeat access to prehospital/ED care, among those, 8 (18.6%) were related to hypoglycemia. Patients on insulin were less likely to have repeat access to prehospital/ED care (AdjOR 0.4; 95%CI 0.2-0.9). This was not impacted by initial (or refusal of) transport (AdjOR 1.1; 95%CI 0.5-2.4).

CONCLUSION

Although risk of repeat access to prehospital/ED care for patients with hypoglycemia exists, it was less common among patients taking insulin and was not predicted by an initial refusal of transport.

Out-of-hospital hypoglycaemia is safely and cost-effectively treated by paramedics

OBJECTIVES

The purpose of this study was to investigate the clinical epidemiology of severe out-of-hospital hypoglycaemia, to evaluate the standard treatment protocol used, to investigate the clinical outcome during a 3-month follow-up period and to evaluate financial savings achieved by not transporting all patients to hospital.

METHODS

This study was a prospective, observational study based on questionnaires and patient files. Two paramedic units of the Rescue Department filled in a study form on each hypoglycaemia patient they enrolled between 1 February 2001 and 31 December 2001. These patients were contacted by mail after 3 months and asked to fill in a questionnaire regarding their health.

RESULTS

Sixty-nine patients were included in the study. The majority of the patients had diabetes mellitus for more than 5 years. The severity of hypoglycaemia was related to the duration of diabetes (P = 0.003) and insulin therapy (P = 0.021). Fifty-eight patients (84.1%) required intravenous glucose treatment. Sixty-two patients (89.9%) were left at the scene after treatment. No immediate relapses occurred. Mean patient satisfaction was 4.6 (SD 0.8) on a scale from 1 to 5. Satisfaction was related to the duration of diabetes (P<0.0001) and to low haemoglobin A1c values (P<0.0001). The direct savings achieved by not transporting the patient to the hospital emergency department were estimated to be 398.5 per patient.

CONCLUSION

The emergency medical services guideline for the treatment of hypoglycaemia and the practice of leaving selected patients at the scene after treatment were found to be effective, safe and economical. Patient satisfaction was found to be high, further supporting the practice of not transporting all patients to hospital.

A comparison of glucagon and glucose in prehospital hypoglycaemia

OBJECTIVE

To compare intramuscular glucagon with intravenous glucose in the prehospital management of hypoglycaemia in adults.

METHODS

In the first part of the trial all UK ambulance services were asked how their personnel treat prehospital episodes of hypoglycaemia. In the second part, two protocols for treating prehospital hypoglycaemia were studied. In phase 1, intramuscular glucagon 1 mg was used. In phase 2, intravenous glucose 25 g was used; if intravenous access was not possible, intramuscular glucagon was given.

RESULTS

33 out of 43 respondent ambulance services (76.7%) only use glucagon for prehospital hypoglycaemia; the remaining services use glucose and glucagon. In the second part of the study the median duration from diagnosis to full orientation (Glasgow coma score 15) was 28 minutes (95% confidence interval 18 to 49 minutes) in phase 1 and 11 minutes (95% confidence interval 8 to 19 minutes) in phase 2. This difference is statistically significant (P < 0.005). On-scene times were not significantly different.

CONCLUSIONS

Intravenous glucose is the treatment of choice in prehospital hypoglycaemia but glucagon should also be available for intramuscular use when intravenous access is not possible.

An audit of cardiac arrest management by extended trained ambulance crew

OBJECTIVE

To audit the use of extended skills by South Glamorgan Ambulance crew in attempted resuscitations from out-of-hospital cardio-respiratory arrest, in terms of successful discharge of patients from hospital and the accuracy with which agreed protocols were applied. Design-Retrospective analysis of ambulance report forms, electrocardiograph rhythm strips, casualty cards and discharge summaries during 26 months (1st May 1987-30th June 1989).

SETTING

A mixed urban and semi-rural area of 187 square miles with a population of 396,000.

RESULTS

There were 274 attempted resuscitations. Seven patients (2.5%) were managed for primary respiratory arrest and 3 were discharged. In 98 patients (35.8%) the initial resuscitation protocol was for ventricular fibrillation: 26 were admitted and 17 were discharged. In 169 patients (61.7%) the initial resuscitation protocol was for asystole or electromechanical dissociation: 11 were admitted and 1 discharged. The majority of patients who were successfully discharged from hospital were those in ventricular fibrillation who responded to defibrillation alone (13 survivors). Drug administration may have played a role in the successful resuscitation of the remainder. Endotracheal intubation was successful in 94.7% and vein cannulation in 87.7% of attempts. There were deviations from the ventricular fibrillation protocol in 27 cases (27.5%) and from the asystole protocol in 27 cases (16.0%).

CONCLUSION

Survival rates for ventricular fibrillation managed by these personnel were satisfactory with early defibrillation. Defibrillation alone was responsible for the majority of successful resuscitations. The additional benefit of drug administration appears small, though potentially important. The majority of patients were in asystole by the time the ambulance arrived.

IMPLICATIONS

Extended trained crews use their skills effectively. The most important skill is defibrillation. Further studies are required to explain the high proportion of patients found in asystole. The performance of individual ambulance personnel should be assessed prospectively, because agreed resuscitation protocols are not always followed.

Audit of an emergency ambulance service: impact of a paramedic system

The purpose of this survey was to assess the workload of an emergency ambulance service, to describe the use of paramedic skills by those staff with full extended training, and to predict the impact upon the provision of pre-hospital care of deploying a paramedic on every emergency ambulance. Accordingly, a week-long survey was undertaken of all urgent and emergency calls received by an ambulance service covering a mixed urban and semi-rural area of 187 square miles with a population of 396,000. Of the total 682 emergency calls 351 (51.5%) originated from the '999' system: 291 of these patients were taken to hospital where 51% were thought to have minor conditions and 141 were admitted. General practitioners made 236 (34.6%) emergency calls: 234 patients were taken to hospital where 76.4% were thought to have potentially serious conditions or an acute risk to life and 217 were admitted. There was no difference in the type or severity of conditions attended by paramedic or non-paramedic crews. Time spent on-scene was significantly longer when paramedics were present (mean 11.0 min, 95% confidence interval 9.54-12.46 min v 8.31 min, 7.49-9.13 min) (p less than 0.01). Extended skills were used by paramedics in 42 (23.6%) of their patients, most of whom were medical cases. One patient was resuscitated from cardiac arrest. The presence of a paramedic on every emergency ambulance increases the time spent on-scene and offers advanced pre-hospital skills to patients who need them. Care should be taken to ensure that the benefits of time spent on-scene using such skills outweigh the disadvantage of delayed hospital admission.