Hyperglycemia Visit Research Articles

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

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. 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 30days of the index visit. Using multivariable regression analysis, we examined clinical and socioeconomic predictors for recurrent visits. 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 30days. 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 14days, access to homecare services, and previous hyperglycemia encounters in the past 5years. Alcoholism and depression or anxiety were positive predictors for the 18-65 age group. 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.

Assessing the Revised Safer Dx Instrument® in the understanding of ambulatory system design changes for type 1 diabetes and autism spectrum disorder in pediatrics.

We sought within an ambulatory safety study to understand if the Revised Safer Dx instrument may be helpful in identification of diagnostic missed opportunities in care of children with type 1 diabetes (T1D) and autism spectrum disorder (ASD). We reviewed two months of emergency department (ED) encounters for all patients at our tertiary care site with T1D and a sample of such encounters for patients with ASD over a 15-month period, and their pre-visit communication methods to better understand opportunities to improve diagnosis. We applied the Revised Safer Dx instrument to each diagnostic journey. We chose potentially preventable ED visits for hyperglycemia, diabetic ketoacidosis, and behavioral crises, and reviewed electronic health record data over the prior three months related to the illness that resulted in the ED visit. We identified 63 T1D and 27 ASD ED visits. Using theRevised Safer Dx instrument, we did not identify any potentially missed opportunities to improve diagnosis in T1D. We found two potential missed opportunities (Safer Dx overall score of 5) in ASD, related to potential for ambulatory medical management to be improved. Over this period, 40 % of T1D and 52 % of ASD patients used communication prior to the ED visit. Using the Revised Safer Dx instrument, we uncommonly identified missed opportunities to improve diagnosis in patients who presented to the ED with potentially preventable complications of their chronic diseases. Future researchers should consider prospectively collected data as well as development or adaptation of tools like the Safer Dx.

Predictors of 30-day Recurrent Emergency Department Visits for Hyperglycemia in Patients With Diabetes: A Population-based Cohort Study

Few population-level studies have investigated the health-care burden of emergency department (ED) visits for hyperglycemia. This study's objectives were to describe patients with diabetes presenting with their first ED visit for hyperglycemia and to identify predictors of recurrent ED hyperglycemia visits.

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?

ObjectivesFew 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. MethodsWe 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. ResultsThere 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. ConclusionsPatients 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.

LO53: Emergency department visits for hyperglycemia: through the eyes of the patient

Introduction: Patients with poorly-controlled diabetes often visit the emergency department (ED) for treatment of hyperglycemia. While previous qualitative studies have examined the patient experience of diabetes as a chronic illness, there are no studies describing patients’ perceptions of ED care for hyperglycemia. The objective of this study was to explore the patient experience regarding ED hyperglycemia visits, and to characterize perceived barriers to adequate glycemic control post-discharge. Methods: This study was conducted at a tertiary care academic centre in London, Ontario. A qualitative constructivist grounded theory methodology was used to understand the experience of adult patient partners who have had an ED hyperglycemia visit. Patient partners, purposively sampled to capture a breadth of age, sex, disease and presentation frequency were invited to participate in a semi-structured individual interview to probe their experiences. Sampling continued until a theoretical framework representing key experiences and expectations reached sufficiency. Data were collected and analyzed iteratively using a constant comparative approach. Results: 22 patients with type 1 or 2 diabetes were interviewed. Participants sought care in the ED over other options because of their concern of having a potentially life-threatening condition, advice from a healthcare provider or family member, or a perceived lack of convenient alternatives to the ED based on time and location. Participants’ care expectations centred around symptom relief, glycemic control, reassurance and education, and seeking referral to specialist diabetes care post-discharge. Finally, perceived system barriers that challenged participants’ glycemic control included affordability of medical supplies and medications, access to follow-up and, in some cases, the transition from pediatric to adult diabetes care. Conclusion: Patients with diabetes utilize the ED for a variety of urgent and emergent hyperglycemic concerns. In addition to providing excellent medical treatment, ED healthcare providers should consider patients’ expectations when caring for those presenting with hyperglycemia. Future studies will focus on developing strategies to help patients navigate some of the barriers that exist within our current limited healthcare system, enhance follow-up care, and improve short- and long-term health outcomes.

P143: A prospective cohort study characterizing 30-day recurrent emergency department visits for hyperglycemia

Introduction: Hyperglycemic emergencies, including diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS), often recur in patients who have poorly controlled diabetes. Identification of those at risk for recurrent hyperglycemia visits may improve health care delivery and reduce ED utilization for these patients. The objective of this study was to prospectively characterize patients re-presenting to the emergency department (ED) for hyperglycemia within 30 days of an initial ED visit. Methods: This is a prospective cohort study of patients ≥18 years presenting to two tertiary care EDs (combined annual census 150,000 visits) with a discharge diagnosis of hyperglycemia, DKA or HHS from Jul 2016-Nov 2018. Trained research personnel collected data from medical records, telephoned patients at 10-14 days after the ED visit for follow-up, and completed an electronic review to determine if patients had a recurrent hyperglycemia visit to any of 11 EDs within our local health integration network within 30 days of the initial visit. Descriptive statistics were used where appropriate to summarize the data. Results: 240 patients were enrolled with a mean (SD) age of 53.9 (18.6) years and 126 (52.5%) were male. 77 (32.1%) patients were admitted from their initial ED visit. Of the 237 patients (98.8%) with 30-day data available, 55 (23.2%) had a recurrent ED visit for hyperglycemia within this time period. 21 (8.9%) were admitted on this subsequent visit, with one admission to intensive care and one death within 30 days. For all patients who had a recurrent 30-day hyperglycemia visit, 22/55 (40.0%) reported having outpatient follow-up with a physician for diabetes management within 10-14 days of their index ED visit. 7/21 (33.3%) patients who were admitted on the subsequent visit had received follow-up within the same 10-14 day period. Conclusion: This prospective study builds on our previous retrospective work and describes patients who present recurrently for hyperglycemia within 30 days of an index ED visit. Further research will attempt to determine if access to prompt follow-up after discharge can reduce recurrent hyperglycemia visits in patients presenting to the ED.

P162: Patient-important outcomes in hyperglycemia after discharge from the emergency department: a prospective cohort study

Introduction: Hyperglycemic emergencies, including diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS), carry significant morbidity for individuals even after discharge. The objective of this study was to describe the patient-important outcomes and burden of disease for emergency department (ED) patients with hyperglycemia after discharge from hospital. Methods: This was a prospective cohort study of patients 18 years presenting to two tertiary care EDs (combined annual census 150,000 visits) with a discharge diagnosis of hyperglycemia, DKA or HHS over a 15-month period (Jul 2016-Oct 2017). During the ED visit, consent was obtained for a telephone follow-up call to determine patient-important outcomes. Trained research personnel collected data from medical records and completed a 14 day telephone follow-up using a standardized questionnaire to determine medication changes, missed days of school or work, and repeat admissions or visits to a healthcare provider. Descriptive statistics were used where appropriate to summarize the data. Results: Thus far, 172 patients have been enrolled in our study. Mean (SD) age is 53.9 (19.3) years and 97 (56.4%) are male. 65 (37.8%) patients were admitted from their initial ED visit. Of the 125 patients (72.7%) providing post-discharge outcomes, 75 (60.0%) required an adjustment to their diabetes medications or insulin. 21 (16.8%) patients missed days of school or work for a median (IQR) duration of 3.5 (1.3, 7.0) days. 85 (68.0%) saw another healthcare provider within a 14 day period, 45 (36.0%) saw their family physician, and 34 (27.2%) saw an internist or endocrinologist. 9 (7.2%) were seen again in the ED, 5 of these patients required admission to hospital. There was one death that occurred within the follow-up period. Conclusion: This prospective study builds on our previous retrospective work and demonstrates that visits for hyperglycemia carry a significant burden of disease beyond what may be seen in a single ED encounter. Further research will attempt to identify the factors that may be predictive of adverse outcomes in hyperglycemic patients presenting to the ED.

P140: Risk factors for adverse outcomes in hyperglycemic patients presenting to the emergency department: a systematic review

Introduction: Hyperglycemia is a significant cause of morbidity and mortality, often resulting in adverse outcomes such as recurrent ED visits, hospitalization or death. The objective of this study was to perform a systematic review to identify predictors of these adverse outcomes among patients who present to the ED with hyperglycemia. Methods: Electronic searches of Medline and EMBASE were conducted for studies published in English between the years 1946 and June 2017. Studies with patients presenting to the ED with hyperglycemia were eligible for inclusion. Both adult and pediatric populations were included, as were diabetic and non-diabetic patients. Two reviewers independently screened all titles and abstracts for relevance to the research question. If consensus could not be reached, full-length manuscripts were reviewed. For any discrepancy, a third reviewer was consulted, and disagreement was resolved through discussion. Study quality was assessed using the Newcastle-Ottawa Quality Assessment Scale. Study- and patient-specific data were then extracted and presented descriptively in the systematic review. Results: Thirteen observational studies were included, with a combined total of 664,829 patients. The studies scored between 5 to 8 on the Quality Assessment Scale out of a possible total of 8. Predictors of adverse outcomes included patients in both older and younger (&lt; 25) age groups, history of diabetes, multiple comorbidities, patients requiring insulin, sepsis and hyperlactatemia, access to a family physician, a sentinel hyperglycemia visit in the past month, and triage glucose level &gt; 20 mmol/L. Protective factors included no admissions in the past year, care from a diabetes team while in hospital, systolic blood pressure between 90-150 mmHg and heart rate &gt; 110 bpm. Conclusion: This systematic review found eight predictors and four protective factors for adverse outcomes in patients presenting to the ED with hyperglycemia. These factors should be considered for easier identification of higher-risk patients for adverse outcomes in order to guide management and follow-up.

Sentinel visits in emergency department patients with diabetes mellitus as a warning sign for hyperglycemic emergencies.

Patients with poorly controlled diabetes mellitus may have a sentinel emergency department (ED) visit for a precipitating condition prior to presenting for a hyperglycemic emergency, such as diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS). This study's objective was to describe the epidemiology and outcomes of patients with a sentinel ED visit prior to their hyperglycemic emergency visit. This was a 1-year health records review of patients≥18 years old presenting to one of four tertiary care EDs with a discharge diagnosis of hyperglycemia, DKA, or HHS. Trained research personnel collected data on patient characteristics, management, disposition, and determined whether patients came to the ED within the 14 days prior to their hyperglycemia visit. Descriptive statistics were used to summarize the data. Of 833 visits for hyperglycemia, 142 (17.0%; 95% CI: 14.5% to 19.6%) had a sentinel ED presentation within the preceding 14 days. Mean (SD) age was 50.5 (19.0) years and 54.4% were male; 104 (73.2%) were discharged from this initial visit, and 98/104 (94.2%) were discharged either without their glucose checked or with an elevated blood glucose (>11.0 mmol/L). Of the sentinel visits, 93 (65.5%) were for hyperglycemia and 22 (15.5%) for infection. Upon returning to the ED, 61/142 (43.0%) were admitted for severe hyperglycemia, DKA, or HHS. In this unique ED-based study, diabetic patients with a sentinel ED visit often returned and required subsequent admission for hyperglycemia. Clinicians should be vigilant in checking blood glucose and provide clear discharge instructions for follow-up and glucose management to prevent further hyperglycemic emergencies from occurring.

Risk factors for recurrent emergency department visits for hyperglycemia in patients with diabetes mellitus

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.

P131: Risk factors for recurrent emergency department visits for hyperglycemia in patients with diabetes mellitus

Introduction: 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. Methods: We conducted a one-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. Results: There were 833 ED visits for hyperglycemia in the one-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 &amp;lt;25 years (OR 2.6, 95% CI 1.5-4.7), glucose &amp;gt;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 &amp;gt;110 bpm (OR 0.41, 95% CI 0.23-0.72) were protective factors independently associated with not having a recurrent hyperglycemia visit. Conclusion: This 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.

Addressing Social Determinants of Health from the Emergency Department through Social Emergency Medicine.

Addressing Social Determinants of Health from the Emergency Department through Social Emergency Medicine.

P144: Sentinel visits in emergency department patients with diabetes mellitus as a warning sign for hyperglycemic emergencies

Introduction: Patients with poorly controlled diabetes mellitus (DM) often visit the emergency department (ED) for management of hyperglycemia, diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). Many of these patients have a “sentinel” ED visit for other medical conditions prior to their hyperglycemic visit, which may worsen their glucose control. The objective of this study was to describe the epidemiology and outcomes of patients presenting with a sentinel ED visit prior to their visit for a hyperglycemic emergency. Methods: This was a health records review of patients ≥18 years presenting to one of four tertiary care EDs (combined annual census 300,000) with a discharge diagnosis of DM, hyperglycemia, DKA or HHS in a one-year period. Visits for hypoglycemia were excluded. Trained research personnel collected data from medical records including demographics, clinical history and results of investigations. Electronic charts were reviewed to determine if the patient came to the ED within the prior 14 days of their index hyperglycemia visit, and the details and outcomes surrounding both visits. Descriptive statistics were used where appropriate to summarize the data. Results: From January-December 2014, 609 ED visits had a discharge diagnosis of hyperglycemia. Mean (SD) age was 50.4 (19.5) years, and 343 (56.3%) were male. 101/609 visitors (16.6%) had an ED presentation within the previous 14 days from their hyperglycemia visit. 71 (70.3%) of these were discharged from this initial visit and 49/71 (69.0%) were discharged either without their blood glucose checked or with an elevated blood glucose (&gt;11.0 mmol/L). Of the sentinel visits, 58 (57.4%) were for hyperglycemia and 15 (14.9%) were for infection. Upon returning to the ED, 45/101 (44.6%) visitors were subsequently admitted for management of severe hyperglycemia, DKA or HHS. Conclusion: This unique ED-based study demonstrates that patients with DM presenting with hyperglycemia or infection often return and may ultimately require admission. Clinicians should be vigilant in checking blood glucose when these patients present to the ED and provide clear discharge instructions for follow-up and glucose management. Future research should focus on improving glycemic control in these patients in order to prevent further hyperglycemic emergencies from occurring.

Hemoglobin A1c Testing in an Emergency Department

Emergency department (ED) visits for hyperglycemia are common and costly. Enhanced strategies for recognizing and managing patients with diabetes in the ED are needed. Hemoglobin A1c (A1C) testing is typically used to assess level of glycemic control in the 2-3 months preceding an office visit. In this article, we report on potential roles for point-of-care (POC) A1C testing in the ED for patients presenting with uncontrolled hyperglycemia. We enrolled patients presenting to an urban tertiary care hospital ED with blood glucose (BG) ≥ 200 mg/dl who were otherwise stable for discharge (n = 86) in a prospective, nonrandomized pilot study. Antihyperglycemic medication management, survival-skills diabetes self-management education, and health system navigation were provided. Followup visits took place at 24-72 hours and at 2 and 4 weeks. Point-of-care A1C testing was performed at baseline and at 2 weeks. Baseline A1C results were used by the ED physician and the educator to inform the patient of likely preadmission glycemic classification, and the potential role that the (diabetes mellitus) DM medication regimen assigned in the ED had in enabling overall progress in glycemic control at 2 weeks post-ED initiation of treatment. At baseline, 50% of POC A1C values were >13%. Mean BG fell from 356 ± 110 mg/dl to 183 ± 103 mg/dl at 4 weeks (average decrease of 173.5 g/dl, p < 0.001). Mean A1C fell by 0.4%, from 12.0 ± 1.5% to 11.6 ± 1.6% at 2 weeks, p = 0.048. There were zero instances of day 1 hypoglycemia and overall hypoglycemia rates were low (1.3%). Point-of-care A1C testing in the ED helped inform both the provider and the patient of likely prior glycemic status, including unrecognized or uncontrolled type 2 diabetes, and allowed emphasis of the importance of timely diabetes self-management education and medication management in preventing acute and chronic complications. Followup POC A1C testing at 2 weeks was used to confirm early improvement in glycemic control postintervention.