Improving self-referral for diabetes care following hypoglycaemic emergencies: a feasibility study with linked patient data analysis

Randomised controlled trial of an innovative hypoglycaemia pathway for self-care at home and admission avoidance: a partnership approach with a regional ambulance trust

Background

Hypoglycaemia is a common and potentially life-threatening condition in people with diabetes, commonly caused by medications such as insulin. Hypoglycaemic events often require in-patient treatment and/or follow-up with a diabetes specialist nurse (DSN) or GP to make adjustments to medication. This referral pathway commonly relies on patient self-referral to primary care, and as a result many patients are not actively followed up and go on to experience repeat hypoglycaemic events.

Methods

Randomised controlled trial in partnership with East Midlands Ambulance Service NHS Trust. People with diabetes calling out an ambulance for a severe hypoglycaemic episode and meeting the eligibility criteria were randomised to either a novel DSN-led pathway or to their general practice for routine follow-up. Primary outcome was proportion of participants with a documented consultation with a healthcare professional to discuss the management of their diabetes within 28 days of call-out.

Results

162 people were randomised to one of the pathways (73 DSN arm, 89 GP arm) with 81 (50%, 35 DSN, 46 GP) providing full consent to be followed up. Due to lower than anticipated randomisation and consent rates, the recruitment target was not met. In the 81 participants who provided full consent, there were higher rates of consultation following the call-out when referred to a DSN compared to primary care (90% vs. 65%). Of the 81 participants, 26 (32%) had a second call-out within 12 months.

Conclusions

Consultation rates following the call-out were high in the DSN-led arm, but there was insufficient power to complete the planned comparative analysis. The study highlighted the difficulty in recruitment and delivery of research in pre-hospital emergency care. Further work is needed to provide more feasible study designs and consent procedures balancing demands on ambulance staff time with the need for robust well-designed evaluation of referral pathways.

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.

Exploring variation in ambulance calls and conveyance rates for adults with diabetes mellitus who contact the Northern Ireland Ambulance Service: a retrospective database analysis

Background:

People with diabetes frequently contact the ambulance service about acute problems. Overall, treating diabetes and its associated complications costs the NHS 10% of the annual budget. Reducing unnecessary hospital admissions and ambulance attendances is a high priority policy for the NHS across the UK. This study aimed to determine the characteristics of emergency calls for people with diabetes who contact the ambulance service and are subsequently conveyed to hospital by the Northern Ireland Ambulance Service (NIAS).

Methods:

A retrospective dataset from the NIAS was obtained from the NIAS Trust’s Command and Control system relating to calls where the final complaint group was ‘Diabetes’ for the period 1 January 2017 to 23 November 2019.

Results:

Of a total 11,396 calls related to diabetes, 63.2% of callers to the NIAS were conveyed to hospital. Over half of the calls related to males, with 35.5% of callers aged 60–79. The more deprived areas had a higher frequency of calls and conveyance to hospital, with this decreasing as deprivation decreased. Calls were evenly distributed across the week, with the majority of calls originating outside of GP working hours, although callers were more likely to be conveyed to hospital during working hours. Calls from healthcare professionals were significantly more likely to be conveyed to hospital, despite accounting for the minority of calls.

Conclusion:

This research found that older males were more likely to contact the ambulance service but older females were more likely to be conveyed to hospital. The likelihood of conveyance increased if the call originated from an HCP or occurred during GP working hours. The availability of alternative care pathways has the potential to reduce conveyance to hospital, which has been particularly important during the COVID-19 pandemic. Integration of data is vitally important to produce high quality research and improve policy and practice in this area.

Hypoglycemia requiring paramedic assistance among adults in southwestern Ontario, Canada: a population-based retrospective cohort study

BACKGROUND

People with diabetes mellitus commonly experience hypoglycemia, but they may not necessarily present to hospital after severe hypoglycemia requiring paramedic assistance. We sought to describe the incidence and characteristics of calls for hypoglycemia requiring paramedic assistance among adults in southwestern Ontario, Canada, and to determine predictors of hospital transport.

METHODS

This population-based retrospective cohort study used data extracted from ambulance call reports (ACRs) of 8 paramedic services of the Southwest Ontario Regional Base Hospital Program from January 2008 to June 2014. We described calls in which treatment for hypoglycemia was administered, summarized the incidence of hypoglycemia calls and performed logistic regression to determine predictors of hospital transport.

RESULTS

Out of 470 467 ACRs during the study period, 9185 paramedic calls occurred in which hypoglycemia treatment was administered to an adult (mean age 60.2 yr, 56.8% male, 81.1% with documented diabetes). Refusal of hospital transport occurred in 2243 (24.4%) of calls. Documented diabetes diagnosis (adjusted odds ratio [OR] 0.82, 95% confidence interval [CI] 0.69-0.96), higher capillary blood glucose (adjusted OR 0.31, 95% CI 0.22-0.44) and overnight calls (adjusted OR 0.80, 95% CI 0.72-0.91) were associated with lower odds of hospital transport. Higher-acuity calls (adjusted OR 2.05, 95% CI 1.58-2.66) were associated with higher odds of transport. The estimated annual incidence rate of hypoglycemia requiring paramedic assistance was 108 per 10 000 people with diabetes per year.

INTERPRETATION

Hypoglycemia requiring paramedic assistance in southwestern Ontario is common, and close to 25% of calls do not result in hospital transport. Physicians managing diabetes care may be unaware of patients' hypoglycemia requiring paramedic care, suggesting a potential gap in follow-up care; we suggest that paramedics play an important role in identifying those at high recurrence risk and communicating with their care providers.

Patient and paramedic experiences with a direct electronic referral programme for focused hypoglycaemia education following paramedic service assist-requiring hypoglycaemia in London and Middlesex County, Ontario, Canada

AIMS

Hypoglycaemia is a common treatment consequence in diabetes mellitus. Prior studies have shown that a large proportion of people with paramedic assist-requiring hypoglycaemia prefer not to be transported to hospital. Thus, these episodes are "invisible" to their usual diabetes care providers. A direct electronic referral programme where paramedics sent referrals focused hypoglycaemia education at the time of paramedic assessment was implemented in our region for 18 months; however, referral programme uptake was low. In this study, we examined patient and paramedic experiences with a direct electronic referral programme for hypoglycaemia education postparamedic assist-requiring hypoglycaemia, including barriers to programme referral and education attendance.

METHODS

We surveyed paramedics and conducted semistructured telephone interviews of patients with paramedic-assisted hypoglycaemia who consented to the referral programme and were scheduled for an education session in London and Middlesex County, Canada.

RESULTS

Paramedics and patient participants felt that the direct referral programme was beneficial. A third of paramedics who responded to our survey used the referral programme for each encounter where they treated patients for hypoglycaemia. Patients felt very positive about the referral programme and their paramedic encounter; however, they described embarrassment, guilt and prior negative experience as key barriers to attending education.

CONCLUSIONS

Paramedics and patients felt that direct referral for focused hypoglycaemia education postparamedic assist-requiring hypoglycaemia was an excellent strategy. Despite this, referral programme participation was low and thus there remain ongoing barriers to implementation and attendance. Future iterations should consider how best to meet patient needs through innovative delivery methods.

Reducing unscheduled hospital care for adults with diabetes following a hypoglycaemic event: which community-based interventions are most effective? A systematic review

AIM

To determine which community-based interventions are most effective at reducing unscheduled hospital care for hypoglycaemic events in adults with diabetes.

METHODS

Medline Ovid, CINAHL Plus and ProQuest Health and Medical Collection were searched using both key search terms and medical subject heading terms (MeSH) to identify potentially relevant studies. Eligible studies were those that involved a community-based intervention to reduce unscheduled admissions in adults with diabetes. Papers were initially screened by the primary researcher and then a secondary reviewer. Relevant data were then extracted from papers that met the inclusion criteria.

RESULTS

The search produced 2226 results, with 1360 duplicates. Of the remaining 866 papers, 198 were deemed appropriate based on titles, 90 were excluded following abstract review. A total of 108 full papers were screened with 19 full papers included in the review. The sample size of the 19 papers ranged from n = 25 to n = 104,000. The average ages within the studies ranged from 41 to 74 years with females comprising 57% of the participants. The following community-based interventions were identified that explored reducing unscheduled hospital care in people with diabetes; telemedicine, education, integrated care pathways, enhanced primary care and care management teams.

CONCLUSIONS

This systematic review shows that a range of community-based interventions, requiring different levels of infrastructure, are effective in reducing unscheduled hospital care for hypoglycaemia in people with diabetes. Investment in effective community-based interventions such as integrated care and patient education must be a priority to shift the balance of care from secondary to primary care, thereby reducing hospital admissions.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40200-021-00817-z.

Cuidados de enfermería para la persona adulta, diabética con hipoglucemia: revisión integrativa

Introducción: La hipoglucemia es la complicación más frecuente del tratamiento con insulina en adultos. Los eventos de hipoglucemia severa se asocian con complicaciones a corto, mediano y largo plazo en  pacientes con diabetes ellmitus. Una de las estrategias para reducir  la frecuencia de hipoglucemia son las intervenciones de enfermería y  aunque hay pocos estudios que las enuncian de manera explícita, se ha publicado respecto a las necesidades de dichos pacientes, que permiten determinar características definitorias de  diagnósticos enfermeros y a partir de ellos establecer metas e intervenciones enfermeras, para el cuidado de dichos pacientes.  Objetivo: identificar los cuidados de enfermería para prevenir y controlar los eventos de hipoglucemia en pacientes adultos diagnosticados con diabetes mellitus. Metodología: revisión integrativa, se realizó en seis fases: planteamiento de la pregunta PICO; búsqueda en bases de datos y metabuscadores; lectura crítica; análisis, clasificación, validación por nivel de evidencia y grado de recomendación, y presentación de la información. Resultados: la revisión reportó cinco categorías: factores de riesgo y protectores, miedo a la hipoglucemia, atención brindada al paciente, disminución de la hipoglucemia y descripción del impacto de la hipoglucemia en los pacientes. Conclusiones: a partir de las necesidades reportadas en las 5 categorías de los resultados se determinaron características definitorias y factores relacionados que permitieron formular diagnósticos de enfermería y determinar como principales intervenciones: enseñanza del proceso de enfermedad, medicamentos prescritos, entrenamiento de asertividad, manejo de la hipoglicemia, nutricional y de la medicación, mejorar el afrontamiento, enseñanza individual, facilitar el aprendizaje y potenciación de la disposición de aprendizaje.

Do Adult Patients With Type 1 or 2 Diabetes Who Present to the Emergency Department With Hyperglycemia Have Improved Outcomes if They Have Access to Specialized Diabetes Care?

OBJECTIVES

Few studies have examined the effect of specialized care on patients with diabetes who present to the emergency department (ED) visits for acute hyperglycemia. The objective of this study was to characterize ED patients presenting with hyperglycemia and compare the 30-day outcomes of those followed by specialized diabetes clinics with those not followed. We hypothesized that patients followed by specialized clinics would have improved clinical outcomes compared with those who had no specialized follow up.

METHODS

We conducted this single-centre retrospective cohort study of adults (≥18 years) with an ED visit for hyperglycemia over 1 year (January to December 2014). Data from ED visits were linked to specialized diabetes clinic records, which contained diabetes-specific clinical data not available in ED visit records. Descriptive statistics were summarized and comparisons between groups were performed, when appropriate.

RESULTS

There were 456 patients (55.0% men; mean age, 47.7 years; 46.3% with type 1 diabetes) with 250 followed by the specialized diabetes clinics. The 206 patients who were not followed by the diabetes clinics (45%) were more likely to have a recurrent hyperglycemia ED visit (32.5% vs 9.6%, p<0.001) and to require hospitalization for hyperglycemia (14.1% vs 5.2%, p=0.001) within 30 days of initial presentation.

CONCLUSIONS

Patients followed by specialized diabetes clinics had fewer recurrent ED visits and hospital admissions for hyperglycemia at 30 days compared with those not followed, suggesting that greater continuity of care between endocrinology and emergency medicine may help reduce these adverse outcomes for patients with diabetes.

Outcomes of people with severe hypoglycaemia requiring prehospital emergency medical services management: a prospective study

AIMS/HYPOTHESIS

The aim of this work was to investigate clinical outcomes following severe hypoglycaemia requiring prehospital emergency medical services (EMS) management.

METHODS

We carried out a prospective, observational study of adults with diabetes attended by prehospital EMS for management of severe hypoglycaemia between April 2016 and July 2017. Information on precipitants, hospitalisation, length of hospital stay and recurrence was collected at 1 and 3 months following the episode of severe hypoglycaemia. Median and logistic regression models examined predictive factors.

RESULTS

Five hundred and five adults (61% male, median age 67 years) participated in the study. Fifty-two per cent had type 1 diabetes, 43% type 2 diabetes and 5% were unsure of their diabetes type. Following EMS management of the index episode of severe hypoglycaemia, 50.3% were transported to hospital. Of those transported, 41.3% were admitted to hospital for ongoing management (20.8% of all participants). The following factors predicted hospital admission: older age (OR 1.28 [95% CI 1.02, 1.60] per 10 years), greater number of comorbidities (OR 1.27 [95% CI 1.08, 1.48] per morbidity), moderate-severe injury accompanying the hypoglycaemia (OR 5.24 [95% CI 1.07, 25.8] compared with nil-mild injury) and unknown cause of hypoglycaemia (OR 2.21 [95% CI 1.24, 3.94] compared with known cause). The median (interquartile range) length of hospital stay was 4 (2-7) days. During follow-up, recurrent severe hypoglycaemia attended by prehospital EMS was experienced by 10.7% of participants. Predictive factors of recurrent severe hypoglycaemia in 3 months were decreased HbA_1c (OR 1.97 [95% CI 1.27, 3.06] per 10 mmol/mol decrease) and a greater number of antecedent severe hypoglycaemia episodes (OR 1.12 [95% CI 1.03, 1.23] per episode).

CONCLUSIONS/INTERPRETATION

Following an episode of severe hypoglycaemia managed by EMS, one-fifth of participants required hospital admission, more likely in those with advancing age, increasing comorbidities and injury and one-tenth required EMS again for severe hypoglycaemia in a 3 month period, more likely in those with a greater number of antecedent episodes and lower HbA_1c. Knowledge of these factors associated with admission and recurrence provides an opportunity for development of targeted strategies aimed at prevention of severe hypoglycaemia in those most vulnerable.

Re-contact demographics and clinical characteristics of diabetic patients treated for a hypoglycaemic episode in the pre-hospital environment: a rapid literature review

Introduction:

Diabetes mellitus has been referred to as an ‘epidemic’ and the World Health Organization reported 422 million people with the disease in 2014. Hypoglycaemia is common among emergency presentations, yet understanding around the utilisation of emergency medical services (EMS) for this is incomplete.

Ambulance service referral pathways for those suitable to be treated in the community have been developed as a means of managing this growing demand. However, there is limited evidence to suggest how they should be constructed or implemented.

The aim of this review was to examine patients who re-contacted the health services following EMS non-transport for a hypoglycaemic episode and to determine if risk factors could be identified.

Methods:

Medline/PubMed and CINAHL online databases were searched for papers published between 1998 and 2018 relating to re-contacts following an interaction with EMS. The Cochrane Library online database was also searched, as well as manual searches from key journals. Relevant clinical manuals, guidelines and specific grey literature were also hand searched.

Results:

After duplicates were removed, 260 articles were identified, with 41 selected for full review. These were then reduced by excluding those that did not provide any data on re-contact rates/demographics. The remaining papers were then assessed using the Critical Appraisal Skills Programme (CASP) appraisal tool and those identified as of low quality were removed. This produced 17 papers for final inclusion.

Conclusion:

The literature demonstrates that ambulance clinicians can appropriately treat hypoglycaemia in the community and identify those requiring further assessment at emergency departments. However, due to the very nature of diabetes, repeat episodes will and do occur, regardless of community or emergency department management, but these are rarely in the acute phase. Some groups are higher risk, but thorough holistic assessment is vital for identifying those suitable for community management.

The feasibility, acceptability and preliminary testing of a novel, low-tech intervention to improve pre-hospital data recording for pre-alert and handover to the Emergency Department

Background

Poor communication during patient handover is recognised internationally as a root cause of a significant proportion of preventable deaths. Data used in handover is not always easily recorded using ambulance based tablets, particularly in time-critical cases. Paramedics have therefore developed pragmatic workarounds (writing on gloves or scrap paper) to record these data. However, such practices can conflict with policy, data recorded can be variable, easily lost and negatively impact on handover quality.

Methods

This study aimed to measure the feasibility and acceptability of a novel, low tech intervention, designed to support clinical information recording and delivery during pre-alert and handover within the pre-hospital and ED setting. A simple pre and post-test design was used with a historical control. Eligible participants included all ambulance clinicians based at one large city Ambulance Station (n = 69) and all nursing and physician staff (n = 99) based in a city Emergency Department.

Results

Twenty five (36%) ambulance clinicians responded to the follow-up survey. Most felt both the pre-alert and handover components of the card were either ‘useful-very useful’ (n = 23 (92%); and n = 18 (72%) respectively. Nineteen (76%) used the card to record clinical information and almost all (n = 23 (92%) felt it ‘useful’ to ‘very useful’ in supporting pre-alert. Similarly, 65% (n = 16) stated they ‘often’ or ‘always’ used the card to support handover. For pre-alert information there were improvements in the provision of 8/11 (72.7%) clinical variables. ​ Results from the post-test survey measuring ED staff (n = 37) perceptions of handover demonstrated small (p < 0.05) improvements in handover in 3/5 domains measured.

Conclusion

This novel low-tech intervention was highly acceptable to ambulance clinician participants, improving their data recording and information exchange processes. However, further well conducted studies are required to test the impact of this intervention on information exchange during pre-alert and handover.

Electronic supplementary material

The online version of this article (10.1186/s12873-018-0168-3) contains supplementary material, which is available to authorized users.

Role and prevalence of impaired awareness of hypoglycaemia in ambulance service attendances to people who have had a severe hypoglycaemic emergency: a mixed-methods study

OBJECTIVES

(1) To compare the experiences of people who are affected by diabetes-related hypoglycaemia and either do or do not require an emergency attendance and (2) to measure the prevalence of impaired awareness of hypoglycaemia in patients who are attended by an ambulance service due to a severe hypoglycaemic event.

DESIGN

A sequential mixed-methods study.

SETTING

A qualitative interview study was undertaken with 31 people with diabetes (types 1 and 2) resident in the central belt of Scotland. A national prevalence survey of 590 Scottish Ambulance Service patients who had recently experienced a severe hypoglycaemic emergency requiring ambulance clinicians attendance. Impaired awareness of hypoglycaemia was measured using two standardised measures.

RESULTS

Considerable differences in impaired awareness of hypoglycaemia were found in the experiences of participants who did or did not require the ambulance service to treat their severe hypoglycaemic events. Those who required an ambulance reported fewer warning signs and symptoms. The prevalence of impaired awareness of hypoglycaemia in ambulance service call-outs as assessed by two standardised measures was 53% and 60%, respectively.

CONCLUSIONS

The prevalence of impaired awareness of hypoglycaemia among those who require an ambulance following a hypoglycaemic event is more than twice that found in the general population of people with diabetes. This may be because the experiences of impaired awareness in people who require an ambulance following a severe hypoglycaemic event differ to those who do not. This study provides important information to guide future prehospital clinical practice, and to develop and evaluate theoretically informed interventions. Improvements in prehospital care for this patient population could lead to global improvements in health outcomes and decreased service costs.

A new integrated care pathway for ambulance attended severe hypoglycaemia in the East of England: The Eastern Academic Health Science Network (EAHSN) model

AIMS

We developed a new clinical integrated pathway linking a regional Ambulance Trust with a severe hypoglycaemia (SH) prevention team. We present clinical data from the first 2000 emergency calls taken through this new clinical pathway in the East of England.

METHODS

SH patients attended by Ambulance crew receive written information on SH avoidance, and are contacted for further education through a new regional SH prevention team. All patients are contacted unless they actively decline.

RESULTS

Median age (IQR) was 67 (50-80) years, 23.6% of calls were for patients over 80years old, and patients more than 90years old were more common than 20-25year olds in this population. Most calls were for patients (84.9%) who were insulin treated, even those over 80years (75%). One - third of patients attended after a call were unconscious on attendance. 5.6% of patients in this call population had 3 or more ambulance call outs, and they generated 17.6% of all calls. In total, 728 episodes (36.4%) were repeat calls. Insulin related events were clinically more severe than oral hypoglycaemic related events. Patients conveyed to hospitals (13.8%) were significantly older, with poorer recovery in biochemical hypoglycaemia after ambulance crew attendance. Only 19 (1%) opted out of further contact. Patients were contacted by the SH prevention team after a median 3 (0-6) days. The most common patient self - reported cause for their SH episode was related to perceived errors in insulin management (31.4%).

CONCLUSIONS

This new clinical service is simple, acceptable to patients, and a translatable model for prevention of recurrent SH in this largely elderly insulin treated SH population.