3 results
LO53: Emergency department visits for hyperglycemia: through the eyes of the patient
- J. Yan, D. Azzam, S. Liu, T. Spaic, M. Columbus, K. Van Aarsen, L. Shepherd
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 22 / Issue S1 / May 2020
- Published online by Cambridge University Press:
- 13 May 2020, p. S26
- Print publication:
- May 2020
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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.
GD06: Derivation and internal validation of a clinical prognostic tool for recurrent emergency visits for hyperglycemia in patients with diabetes mellitus: a multicentre prospective cohort study
- J. Yan, K. Gushulak, T. Spaic, S. Liu, L. Siddiqi, K. van Aarsen, S. McLeod, D. Eagles, B. Borgundvaag, I. G. Stiell
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 19 / Issue S1 / May 2017
- Published online by Cambridge University Press:
- 15 May 2017, pp. S64-S65
- Print publication:
- May 2017
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Background: Patients with poorly controlled diabetes mellitus (DM) often visit the emergency department (ED) for management of hyperglycemic episodes, including diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). It has been previously reported that risk factors for readmission to the intensive care unit (ICU) in DKA include older age, female sex and the presence of significant comorbidity including sepsis. However, there are no ED-based studies on this topic, particularly in a Canadian setting, and data on outcomes such as recurrent ED visits, hospital or ICU admission after discharge in these patients is lacking. Objectives: The primary objective of this study is to derive and internally validate a clinical risk tool for prognosis of patients presenting with hyperglycemic emergencies to identify those at higher risk of adverse outcomes within 30 days of initial ED presentation. Methods: This will be a multicentre prospective cohort study of eligible consecutive adult patients with an ED diagnosis of hyperglycemia, DKA or HHS. We will include all visits of adult (≥18 years) ED patients with either a known or unknown history of DM and a diagnosis of hyperglycemia (blood glucose >11.0 mmol/L), DKA or HHS. We will include patients with co-morbid diagnoses in addition to hyperglycemia. We will exclude patients: a) with advanced care directives for resuscitation involving refusal of treatment, and b) who are initially assessed at a peripheral hospital and transferred to our sites for ongoing management. Research assistants will then contact the enrolled participants via telephone for follow-up regarding clinical outcomes, including repeat visits to see a health care provider, changes in diabetic medications, and time taken off of work or school. Participants will be followed to determine if they have further ED visits, admissions or ICU admissions after their ED visit for hyperglycemia. Data on missed patients or those who refused consent will be collected to assess for selection/enrolment bias. Statistical considerations: The primary outcome will be an unplanned return ED visit for hyperglycemia within 30 days of initial presentation. Secondary outcomes will include unplanned admission to hospital or ICU for hyperglycemia, or death within 30 days of the index ED visit. Additionally, we hope to characterize patient-important and health-care system outcomes such as time taken off work or school and follow-up visits to see a healthcare provider. We will conduct descriptive statistics on investigations, treatments, disposition and patient-important outcomes. We will perform an initial univariate logistic regression, followed by a multivariate analysis to identify predictor variables associated with adverse events such as recurrent ED visits, and admission to hospital or ICU for hyperglycemia within 30 days. We will include individual patients who have multiple recurrent visits to the ED during the study period and statistically weight for these using generalized estimating equations (GEE), which are used to develop regression models for correlated data that arise from repeated measures of the same individuals over time. Finally, a clinical risk tool will be derived by rounding the beta co-efficients. Internal validation will be conducted using bootstrapping techniques. Importance: ED visits for hyperglycemia significantly affect both the healthcare system overall and the individual patient. The results of this project will assist clinicians to better identify these patients and enable them to intervene either medically or educationally to prevent subsequent visits to the ED. As a result, patients will have improved care, better blood glucose control, and be identified for closer follow-up with a family physician or diabetes specialist. Furthermore, by aiming to reduce the number of recurrent visits, this project may reduce ED utilization and the associated healthcare costs with frequent visits and admissions for hyperglycemia.
P027: Emergency medical services (EMS) assist-requiring hypoglycemia in Southwest Ontario
- M. Peddle, S. Liu, H. Reid, M. Columbus, J. Mahon, A. Dukelow, T. Spaic
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 18 / Issue S1 / May 2016
- Published online by Cambridge University Press:
- 02 June 2016, p. S87
- Print publication:
- May 2016
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Introduction: Hypoglycemia is a common treatment consequence in diabetes mellitus (DM) and the second most common cause of Emergency Department (ED) visits for adverse drug events. Prior studies have examined the rates of ED visits and inpatient hospitalizations for hypoglycemia. These represent only a small proportion of severe hypoglycemic events, as many do not present to hospital. To date, there have been no Canadian population-based studies examining the rates of EMS assist-requiring hypoglycemia in DM patients in the pre-hospital setting. The objective of this study was to determine the prevalence and describe the EMS assist-requiring hypoglycemia in DM patients in Southwestern Ontario. Methods: A population-based retrospective cohort study was conducted on all EMS calls for diabetic emergency from 2008-2014 in Southwestern Ontario, Canada. Data was extracted from the electronic ambulance call records for 11 EMS services in the region. Results: There were 9,265 EMS calls for a diabetic emergency (mean age 59 ± 20 years, 57% male, 82% DM). For 223 calls (2.4%) patients were younger than 19 years of age. The mean blood glucose level on presentation was 2.49 ± 1.02 mmol/L and 2,116 (24%) call subjects had initial GCS score less than 9. Treatment (intravenous glucose or IM glucagon) was given in 7,126 (77%) calls. There were 3,884 (51 %) hypoglycemia episodes with documented insulin use and 1,436 (19 %) documented oral hypoglycemia agents use. Between 2008 and 2014, rates of calls increased by 7.4% (p<0.0001). Prevalence of hypoglycemia calls during the study period was estimated at 189 per 10,000 diabetes patients per year. In 2,297 (24.8%) instances, the patient refused transport to the ED. Conclusion: The rates of EMS assist-requiring hypoglycemia are almost double the rates of hospitalization/ED visits for acute DM complications in our region. Many life threatening episodes of hypoglycemia may go unreported and subsequently not followed by the patient's primary health care provider. Further assessment and proper education following those episodes may help decrease the rate of severe hypoglycemia.