Author: Dr. Nupur Shah
Article: Comparison of Two Glycemic Discharge Goals in ED Pts with Hyperglycemia, a randomized trial.
Have you ever had a patient that comes in with a complaint and you happen to check basic labs and their blood glucose comes back at >400? You plan to discharge this patient since they don’t have any indications for hospitalization, but you think twice to yourself if you should give them insulin to bring down their blood glucose to a “reasonable” amount prior to discharge. This study wanted to assess whether bringing down a blood glucose level in patients that were deemed for discharge had any adverse seven day outcomes and how it influenced their length of stay in the emergency department.
This was a prospective, randomized study that took place at an urban, county, academic level 1 trauma hospital with approximately 100,000 annual ED visits. Patient selection was based on whether the patients were 1) greater than 18 years old, 2) were ED patients that were intended for discharge by their ER provider and had blood glucose levels between 400 and 600, 3) patients had working phones and willing to discuss their health status one week after enrollment. Those that were excluded from the study included those with type 1 diabetes mellitus, those that already received insulin in the ED, patients that did not speak English, patients that had DKA or were otherwise critically ill (in the opinion of the treating physician), patients that were prisoners, patients that were pregnant, and patients that were unable to provide informed consent.
Patients were randomly assigned a discharge glucose goal of less than 350 mg/dL (moderate control) or less than 600 mg/dL (loose control). The primary outcome of this study included emergency department length of stay between these two groups. The secondary outcome of this study included repeat ED visits for hyperglycemia, hospitalization for any reason except trauma, or repeat ED visit for any reason within 7 days, and iatrogenic hypoglycemia. Emergency medicine providers were provided recommendations if their patient was in the moderate control group to provide 0.1 to 0.2 units/kg of insulin aspart or patient’s usual home dose of short-acting insulin. At discharge, for patients not currently taking antihyperglycemic agents, it was recommended prescribing glipizide XL 10 mg daily.
The primary outcome, ED length of stay, for the patients that achieved a discharge glucose less than 350 mg/dL was approximately 29 minutes longer compared to the remaining participants. The seven day outcomes were not significantly different whether moderate or loose glycemic control was achieved.
My major takeaway from this study was that short term glycemic control in an otherwise well appearing patient that can be discharged, and that does not have type 1 diabetes, short term glycemic control in the ER is not necessary. It utilizes highly valuable staffing resources such as nursing staff, induces risk such as iatrogenic hypoglycemia, increases length of stay in the Emergency department, and increases costs of the overall ED visit to the patient when at the end of the day it doesn’t really affect 7 day adverse outcome events.
Driver, Brian. Klein, Lauren. Cole, Jon. Prekker, Matthew. Fagerstrom, Erik. Miner, James. “Comparison of Two Glycemic Discharge Goals in ED Pts with Hyperglycemia, a Randomized Trial. .” The American Journal of Emergency Medicine, vol. 37, no. 7, July 2019, doi: https://doi.org/10.1016/j.ajem.2018.09.053.