Mythbuster: Glucose Levels Must be Below a “Safe” Threshold Before Discharge

Background: Anyone who works in the Emergency Department has seen patients brought in by EMS or sent from the clinic with a chief complaint of “high blood sugar.” Now, we are not talking about patients with diabetic ketoacidosis, but just simple hyperglycemia. This is a common complaint with no real consensus on optimal blood glucose levels before safe discharge.

What They Did:

Single Center, Retrospective, Cohort Chart Review

Patients received care determined by the MD working (No actual intervention or protocolized care was followed)

Outcomes:

Determine if there is an association between discharge glucose and 7-day adverse outcomes: Diabetic Ketoacidosis (DKA) Hyperosmolar Hyperglycemic State Repeat ED visit for Hyperglycemia Hospitalization for Any Reason



Inclusion:

≥18 years of age

Glucose Level ≥400 mg/dL at any point during visit

Exclusion:

Admission to the Hospital

Type 1 DM

Chief complaint of Hypoglycemia

Results:

566 Hyperglycemia ED Encounters Included

7 Day Adverse Outcomes: DKA: 2 patients (0.4%) Hyperosmolar Hyperglycemic State: 0 patients (0%) Return Visit for Hyperglycemia: 62 patients (13%) Hospitalization: 36 patients (7%) Death: 0 patients (0%)

Mean Glucose at Discharge: With 7-Day Adverse Outcome: 317 mg/dL Without 7-Day Adverse Outcome: 336 mg/dL

Seven-Day ED Visit for Hyperglycemia Discharge Glucose Level >350 mg/dL: OR 0.69 (95% CI: 0.26 – 1.82) Intravenous Fluids Received: OR 0.92 (95% CI 0.65 – 1.30) Insulin Received: OR 0.99 (0.94 – 04)



Strengths:

Outcome measures were patient-oriented

Countywide ambulance records were reviewed to look for patient visits to other EDs

Only 71 patients (13%) lost to follow up

Interobserver agreement in this study was excellent

Limitations:

Abstractors not blinded to study outcomes, but data for the outcome of interest were collected before other data points

Retrospective study design causes some limitations such as incomplete values in the charts

Care wasn’t standardized. Why some patients got certain treatments prior to discharge was not clear from this trial

Discussion:

It is important to remember that the assumed rates of repeat ED visits for hyperglycemia and hospitalizations have no previous data.

This is the first investigation describing ED treatments and 7-day outcomes for patients with elevated blood glucose levels, not in DKA.

Treatment of hyperglycemia is not without risk. 9 patients (2%) developed iatrogenic hypoglycemia

Author Conclusion: “ED discharge glucose in patients with moderate to severe hyperglycemia was not associated with 7-day outcomes of repeat ED visit for hyperglycemia or hospitalization. Attaining a specific glucose goal before discharge in patients with hyperglycemia may be less important than traditionally thought.”

Clinical Take Home Point: A more appropriate approach to simple hyperglycemia, may be ensuring appropriate outpatient follow up for long-term glycemic control, just as we currently do for asymptomatic hypertension, instead of reaching a “safe” glucose threshold before discharge.

References:

Driver BE et al. Discharge Glucose is Not Associated With Short-Term Adverse Outcomes in Emergency Department Patients With Moderate to Severe Hyperglycemia. Ann Emerg Med 2016; S0196 – 0644 (16): 30162 – 7. PMID: 27353284

For More Thoughts on This Topic Checkout:

Matt Rogers at CORE EM: Relevance of Discharge Glucose Levels and Adverse Events

Post Peer Reviewed By: Anand Swaminathan (Twitter: @EMSwami)