Abstract
BackgroundPatients with poorly controlled diabetes mellitus may present repeatedly to the emergency department (ED) for management and treatment of hyperglycemic episodes, including diabetic ketoacidosis and hyperosmolar hyperglycemic state. The objective of this study was to identify risk factors that predict unplanned recurrent ED visits for hyperglycemia in patients with diabetes within 30 days of initial presentation.MethodsWe conducted a 1-year health records review of patients ≥18 years presenting to one of four tertiary care EDs with a discharge diagnosis of hyperglycemia, diabetic ketoacidosis, or hyperosmolar hyperglycemic state. Trained research personnel collected data on patient characteristics and determined if patients had an unplanned recurrent ED visit for hyperglycemia within 30 days of their initial presentation. Multivariate logistic regression models using generalized estimating equations to account for patients with multiple visits determined predictor variables independently associated with recurrent ED visits for hyperglycemia within 30 days.ResultsThere were 833 ED visits for hyperglycemia in the 1-year period. 54.6% were male and mean (SD) age was 48.8 (19.5). Of all visitors, 156 (18.7%) had a recurrent ED visit for hyperglycemia within 30 days. Factors independently associated with recurrent hyperglycemia visits included a previous hyperglycemia visit in the past month (odds ratio [OR] 3.5, 95% confidence interval [CI] 2.1–5.8), age <25 years (OR 2.6, 95% CI 1.5–4.7), glucose >20 mmol/L (OR 2.2, 95% CI 1.3–3.7), having a family physician (OR 2.2, 95% CI 1.0–4.6), and being on insulin (OR 1.9, 95% CI 1.1–3.1). Having a systolic blood pressure between 90–150 mmHg (OR 0.53, 95% CI 0.30–0.93) and heart rate >110 bpm (OR 0.41, 95% CI 0.23–0.72) were protective factors independently associated with not having a recurrent hyperglycemia visit.ConclusionsThis unique ED-based study reports five risk factors and two protective factors associated with recurrent ED visits for hyperglycemia within 30 days in patients with diabetes. These risk factors should be considered by clinicians when making management, prognostic, and disposition decisions for diabetic patients who present with hyperglycemia.
Highlights
Patients with poorly controlled diabetes mellitus may present repeatedly to the emergency department (ED) for management and treatment of hyperglycemic episodes, including diabetic ketoacidosis and hyperosmolar hyperglycemic state
The emergency physician made a new diagnosis of diabetes mellitus in 12.1% of patients who were presenting to the ED with hyperglycemia, and alcohol-related causes were the precipitant for the hyperglycemic visit in 4.2% of all cases
A final discharge diagnosis of “hyperglycemia” without diabetic ketoacidosis or hyperosmolar hyperglycemic state may not be clinically meaningful or patientimportant, especially if patients had a long history of poor control and were chronically hyperglycemic. This unique exploratory ED-based study reports five risk factors and two protective factors independently associated with unplanned recurrent ED visits for hyperglycemia within 30 days in patients with diabetes
Summary
Patients with poorly controlled diabetes mellitus may present repeatedly to the emergency department (ED) for management and treatment of hyperglycemic episodes, including diabetic ketoacidosis and hyperosmolar hyperglycemic state. The objective of this study was to identify risk factors that predict unplanned recurrent ED visits for hyperglycemia in patients with diabetes within 30 days of initial presentation. Diabetes mellitus is a chronic disease where treatment is directed toward limiting its potentially severe short- and long-term complications. Emergency physicians play a crucial role in managing patients with diabetes, when they present to the ED with acute and potentially severe complications of their disease process [7, 8]. Hyperglycemic emergencies, including diabetic ketoacidosis and hyperosmolar hyperglycemic state, are known to recur in patients with poorly controlled diabetes [7, 9]. The ability to identify hyperglycemic patients at higher risk of ED recidivism may be useful for clinicians in order to guide management and disposition decisions including closer follow-up and tighter glycemic control
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