Evaluating the Emergency Department Observation Unit for the management of hyperglycemia in adults

Risk factors associated with frailty in older adults with type 2 diabetes: A cross-sectional study

AIMS AND OBJECTIVES

The aims of the study were to (i) estimate the prevalence of frailty among older adults with type 2 diabetes, and (ii) investigate risk factors associated with frailty in the study group.

BACKGROUND

The high prevalence of frailty among older adults and its adverse health impacts including higher risks for physical disabilities and a higher mortality rate is quickly evolving to become an important public health issue.

DESIGN

A cross-sectional design.

METHODS

Data were collected from the Clinical Diabetes Centre of our study group. Frailty was assessed using the Chinese version of the Tilburg frailty indicator. Other questionnaires included Activities of Daily Living, Mini-Mental State Examination, Taiwan Geriatric Depression Scale and Instrumental Activities of Daily Living. Multivariable logistic regression was established to identify factors associated with frailty. The STrengthening the Reporting of OBservational studies in Epidemiology checklist was used preparing the manuscript.

RESULTS

A total of 248 subjects were recruited in this study, a total of 66 participants had frailty (26.6%). Our results showed that factors including age, number of chronic diseases, cerebrovascular accident, renal diseases, frequency of falling, frequency of hyperglycaemia, Activities of Daily Living, depression, Mini-Mental State Examination, and Instrumental Activities of Daily Living ≧1 task disability were correlated with frailty in older adults with type 2 diabetes. After adjusting for confounding factors, multivariate logistic regression analyses showed a significant increase in the probability of frailty by 1.72-times when comparing type 2 diabetes subjects with depression to those without depression.

CONCLUSION

This study revealed that depression is a significant factor associated with the occurrence of frailty among older adults with type 2 diabetes.

RELEVANCE TO CLINICAL PRACTICE

Our results provided strong clinical evidence showing depression as an important factor associated with the risk of frailty in older individuals with type 2 diabetes. We recommend early detection via routine screenings for symptoms of depression during diabetes care to achieve early prevention or the delay of frailty and its implicated adverse health consequences.

Use of Endocrine Consultation for HbA1c ≥ 9.0% as a Standardized Practice in an Emergency Department Observation Unit

OBJECTIVE

Severely uncontrolled Diabetes Mellitus (DM) is associated with poor long-term outcomes, and may remain unrecognized. A high frequency of uncontrolled DM has been identified in the acute care setting, including the Emergency Department Observation Unit (EDOU). We assess the use of standardized endocrine consultation in the EDOU for Hemoglobin A1c (HbA1c) ≥ 9%.

MATERIALS AND METHODS

Standard practice in our EDOU includes universal HbA1c screening and endocrine consultation for HbA1c ≥ 9.0%. As part of a quality improvement program, EDOU patients with HbA1c ≥ 9.0% had an endocrinology consult. One month follow up phone calls assessed effects of consultation after discharge.

RESULTS

3,688 (95.7%) of 3,853 EDOU patients received an HbA1c test. 7.0% (n=258) were found to have HbA1c ≥ 9% (Mean HbA1c 11.7 ±1.8%; range 9 - 16.6%). Endocrine consults were completed for 190/258 (73.6%) patients with severely uncontrolled DM. Among the 190 patients, 92.1% (n=175) had discharge DM medication adjustments. Known DM patients (n=142) injectable diabetes medication prescriptions increased from 47.2% (67/142) on EDOU arrival to 78.2% (111/142) on discharge. Newly diagnosed DM injectable prescriptions increased from 0% (0/48) on arrival to 72.9% (35/48) on discharge. A total of 72.6% (n=138) were contacted at one-month and 94.9% (n=131) reported taking DM medications compared to 68.2% (n=94) prior to consult.

CONCLUSIONS

HbA1c screening coupled with endocrine consultation for HbA1c ≥ 9.0% was assessed as a performance improvement study and shown to have valuable results. Further study is recommended to determine long-term clinical impact and cost analysis of this novel approach.

24-hr observation unit is safe location for rapid glucose control in uncomplicated severe hyperglycaemia

Background

Uncomplicated hyperglycaemia is a common presentation in the emergency department (ED). Rapid glucose control is associated with the risk of iatrogenic hypoglycaemia. We sought to determine the safety of a rapid glucose control protocol delivered in a 24-h emergency department observation unit (OU).

Methods

This is a retrospective chart review of patients admitted to the OU for hyperglycaemia where the assessing clinician deemed there was no other reason for medical admission apart from hyperglycaemia; and that the patient could be safely discharged provided their hyperglycaemia was adequately treated. The rapid glucose control protocol consists of 4–6 hourly glucose monitoring and insulin injections according to a sliding scale. We report the demographics, reduction in glucose values and the incidence of hypoglycaemia in the OU. We also determine the rate of discharge from OU and the rate of hospital admission at 30 days.

Results

We included 101 patients. The mean age was 53.5 years (95% CI 50.4–56.6) and 64% of patients were male. The mean HbA1c value was 12.8% (95% CI 12.3–13.3). The mean admission and discharge glucose values were 27.2 (95% CI 26.3–28.1) and 13.9 (95% CI 13.2–14.6) mmols/l respectively. There was no incidence of hypoglycaemia in the OU. We successfully discharged 90.1% of the patients from the OU, of which 3 (3.3%) patients were admitted to the hospital within 30 days of discharge.

Conclusion

ED OU is a safe location to deliver effective management for patients presented with uncomplicated severe hyperglycaemia.

Comparison of two glycemic discharge goals in ED patients with hyperglycemia, a randomized trial

STUDY OBJECTIVE

Hyperglycemia is commonly encountered in the ED; the importance of glucose reduction in patients well enough to be discharged is unknown.

METHODS

We conducted a prospective, randomized trial of ED patients with hyperglycemia with a glucose value 400-600 mg/dL who were discharged from the ED, excluding those with type 1 diabetes mellitus. Patients were randomly assigned to a discharge glucose goal, <350 mg/dL (moderate control) or < 600 mg/dL (loose control). The primary outcome was ED length of stay.

RESULTS

Among 110 enrolled patients, 57 were assigned to moderate and 53 to loose glycemic control. Median (IQR) length of stay was 211 min (177-288 min) for the moderate group and 216 min (151-269 min) for the loose group (difference, 17 min [95% CI -15 to 49 min]). ED length of stay for those with an actual discharge glucose <350 mg/dL was 29 min longer (95% CI -1 to 59 min). Repeat ED visits for hyperglycemia (7% vs 6%), hospitalization for hyperglycemia (0% vs 2%), and hospitalization for any reason (4% vs 8%) did not differ significantly between groups.

CONCLUSION

In the intention-to-treat analysis, ED length of stay and 7-day outcomes were not significantly different whether moderate or loose glycemic control was pursued. However, the length of stay for those with discharge glucose <350 mg/dL was approximately 29 min longer. ED glycemic control did not appear to be associated negative short-term outcomes. Glucose reduction in well-appearing ED patients may consume time and resources without conferring short- or long-term benefits.

TRIAL REGISTRATION

Clinicaltrials.govNCT02478190.