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

Abstract

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.

Conversations and Reactions Around Severe Hypoglycaemia (CRASH): Results from the German Cohort of a Global Survey of People with Type 1 Diabetes or Insulin-Treated Type 2 Diabetes and Caregivers

“…This level of use is comparable to that documented nearly 20 years ago in Germany, where 5 % of patients who presented to hospitals with severe hypoglycaemia received glucagon [19]. Data from other countries vary: a recent prospective, observational study conducted in Australia documented use of glucagon in 5.7 % of patients with severe hypoglycaemia who were treated by prehospital emergency medical services [40] and a 2014 report from Italy found that 1.2 % of patients received glucagon from out-of-hospital emergency services personnel [8]. Other staff at clinical office 2 0 1 0…”

Out-of-Hospital Management of Diabetic Emergencies in Germany: Structural and Process Quality

“…Earlier data from Germany recorded that SH comprised 3% of the total out-of-hospital EMS annual caseload 20 , which is consistent with international figures of 1–4% 12 23 . Currently, only 6% of German emergency physicians have reported that SH had increased in frequency during the last 3–5 years, whereas 13% thought there had been a decrease and 82% considered that there has been no change.…”

“…The pre-conditions for treatment of an SH event without the necessity for hospital admission, are an uncomplicated event in patients who are known to be well educated about the self-management of their diabetes (93 %) and about the use of insulin therapy (44 %). Prospective studies from Germany [21] and Australia [12] in addition to retrospective data from Denmark [22] confirmed the safety of treating SH without hospitalisation in cohorts of selected patients with diabetes. However, in 2020 only a few (11 %) German emergency physicians reported that sulfonylurea-treated patients and older patients with multiple co-morbidities were treated without subsequent hospital admission, a practice that is unchanged from 2001 (9 %).…”

People with diabetes and ambulance staff perceptions of a booklet-based intervention for diabetic hypoglycaemia, “Hypos can strike twice”: a mixed methods process evaluation

“…Reattendance for recurrent hypoglycaemia is also common, affecting 5% within 48 h [ 20 ] and 10% within 3 months [ 21 ]. Current UK guidelines for ambulance services have advocated communicating with primary care or diabetes nurse teams following an episode of hypoglycaemia [ 22 ] but despite this recommendation, follow-up, therapy change or specialist intervention in people self-reporting severe hypoglycaemia are uncommon, suggesting that care pathways are poorly developed or not used [ 21 , 23 ].…”