Major Finding: After the emergency department intervention, mean blood glucose levels dropped by 174 mg/dL, HbA1c went down by at least 0.4 percentage points, and visits to the ED for hypo- or hyperglycemia were reduced by 78%.
Data Source: A pilot study of 86 patients presenting to an ED with uncontrolled hyperglycemia.
Disclosures: The study was funded by the Washington Department of Health. Bayer Pharmaceuticals contributed the A1cNow testing kits and blood glucose meters. Sanofi-Aventis and Novo Nordisk provided insulin pens. Dr. Magee disclosed that she receives support for investigator-initiated grants from Sanofi-Aventis and honoraria for speaking for Sanofi-Aventis and Novo Nordisk. Ms. Nassar stated that she has no disclosures.
SAN ANTONIO – An emergency department intervention delivered by a certified diabetes educator to patients who presented with uncontrolled hyperglycemia reduced the number of repeat visits and improved glycemic control at 6 months without increasing the risk of hypoglycemia.
Use of emergency departments (EDs) for treatment of chronic conditions is a problem both nationally and in the District of Columbia where, in 2006, there were 39,857 ED visits by individuals with diabetes at a cost of about $27 million. A 2008 Rand report estimated that a significant portion of these visits could have been prevented with prior primary care visits and appropriate self-management education, said Dr. Michelle F. Magee, an endocrinologist at Medstar Health Research Institute, Washington Hospital Center.
The Stop Emergency Department Visits for Hypoglycemia Project-DC (Step DC) pilot study – which was initiated in response to a request by ED personnel – enrolled adults who presented to the ED with blood glucose levels of 200 mg/dL or above, whether or not they had a previous diagnosis of type 2 diabetes. (Those with type 1 were excluded.) They had to be stable for discharge once their hyperglycemia was treated, with no other acute comorbidities.
Carine M. Nassar, a certified diabetes educator (CDE) and registered dietician, described the four-visit intervention, comprising three components: using a medication algorithm to achieve glycemic control, focusing on diabetes self-management education “survival skills,” and teaching patients health system navigation skills to find a primary care medical home to reduce future use of the ED for ongoing diabetes care.
The first visit took place while the patient was in the ED. It included point of care hemoglobin A1c and glucose testing, a knowledge questionnaire, and hydration plus insulin therapy. Survival skills education was taught both to those who were newly diagnosed and those who already had been diagnosed with diabetes, many of whom nonetheless lacked basic knowledge of the condition, noted Ms. Nassar, program manager at Medstar Diabetes Institute at Washington Hospital Center.
Patients were discharged with a glucose meter and a prescription for antihyperglycemic medications, based on the treatment algorithm. In general, metformin and/or sulfonylureas were used if blood glucose levels were 200–250 mg/dL, either drug or basal insulin was used for glucose levels of 251–300 mg/dL, and metformin plus insulin – either basal or NPH – was used in patients with glucose levels above 300 mg/dL. Patients who needed insulin were taught to self-administer injections before leaving the ED.
Subsequent outpatient visits took place at 24–72 hours, 2 weeks, and 4 weeks after discharge. These involved a review of blood glucose data with medication adjustments as necessary, continued education, and help with navigation to outpatient clinics or private primary care settings, depending on whether the patient had insurance and what it covered. (Only 15% were uninsured.)
The final visit at week 4 could take place over the phone if the patient so chose and was used to go over any final information, assess glucose data, and ensure that the patient had a follow-up visit in a primary care setting.
The 86 patients had a mean age of 62, 52% were male, and 93% were black. Nearly half (48%) were employed full time; 22% were unemployed. Just over a third (36%) had completed high school or an equivalent. Nearly three-quarters (71%) had never received diabetes self-management education, and 12% received it more than 3 years before the ED visit. “There was a huge knowledge deficit,” said Dr. Magee, who is also with Georgetown University, Washington.
The top three reasons for the ED visit were the inability to get an appointment with a primary care provider, cited by 42%; no primary care provider, 14.5%; and having been sent to the ED by their primary care provider, 10%. “Fully 66.6% came to the ED due to unavailability of primary care that day,” Dr. Magee said.