Discharge glucose is not associated with short-term adverse outcomes in Emergency Department patient
Discharge glucose is not associated with short-term adverse outcomes in Emergency Department patients with moderate to severe hyperglycemia. Driver, et al. Ann Emerg Med. 2016 Dec.
Hyperglycemia is a commonly encountered occurrence in the ED. However, there is no consensus among EM physicians regarding what the “safe” cutoff is for discharge glucose levels. There are currently no established guidelines for EM physicians to follow, and therefore, most practitioners have developed variable cutoffs of what they deem as acceptable hyperglycemia levels. The purpose of this study was to establish if there exists a relationship between discharge glucose levels and 7-day adverse outcomes.
The design of this study was a retrospective chart review conducted at a high-volume urban ED. Inclusion criteria were patients greater than the age of 18 who had a blood glucose greater than 400 mg/dL. Exclusion criteria were if patients were admitted to the hospital, if they had a history of type I diabetes, and any patients whose type of diabetes was not specified. Data was collected from EMR through a comprehensive chart review of eligible ED encounters.
Results: They identified 422 patients with a total of 566 ED encounters. Mean arrival glucose was 491 mg/dL (with a standard deviation of 82 mg/dL) and mean discharge glucose was 334 mg/dL (with a standard deviation of 101). There were a broad range of blood glucose levels which patients were discharged with, again highlighting the idea that ED practitioners have very varied practice styles regarding comfort with blood glucose levels. At the predetermined 7 day period, 62 patients (13%) had a repeat ED visit for hyperglycemia and 36 patients (7% total) ended up hospitalized. Two patients developed DKA. The authors determined that after adjustment for arrival glucose and ED interventions received for elevated BS (intravenous fluids and subcutaneous insulin) the discharge glucose was not associated with repeat ER visits (adjusted OR of 0.997 with 95% CI including 1) or with hospitalization (adjusted OR 0.998 with a 95% CI including 1 as well).
Discharge glucose levels in patients with moderate to severe hyperglycemia (ranging 48 from to 694) was not associated with significant 7-day adverse outcomes in regards to repeat ED visits for hyperglycemia or hospitalization
Although they reported only 2 patients who developed DKA, they excluded the patient population most at risk of developed DKA – type I diabetic patients! This was a retrospective study as well. Limiting the adverse outcomes to only 7 days was also inherently flawed as patients can seek care at outside hospitals, and it can be very difficult to sort out reasons for ED visits and hospitalizations at outside institutions. Furthermore, these results were not applicable to admitted patients and only limited to patients discharged from the ED.
Take Home Point:
Although the study makes the point that there is no “safe cutoff” for discharge glucose levels, it is important to take into consideration why the patient is so hyperglycemic. Are they acutely ill or does their BG always run in the 500s, do they have access to their medications, do they lack medical literacy in their disease process? It is important to assess the entire situation prior to making a decision, and even more so, to talk to the patient about where the gap seems to be.