Determinant The Frequency Of Short-Term Undesirable Events In Diabetes Discharged From The Emergency Department

doi:10.21203/rs.3.rs-1354784/v1

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Determinant The Frequency Of Short-Term Undesirable Events In Diabetes Discharged From The Emergency Department

https://doi.org/10.21203/rs.3.rs-1354784/v1

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Objectives

In our study, we aimed to reveal the frequency and determinants of adverse events in patients with diabetes mellitus, who presented to the emergency department for any reason, had uncomplicated hyperglycemia, but were decided to be treated as an outpatient.

Results

As the patient group with a plasma glucose level of 200 mg/dl and above and normoglycemic diabetic patients were evaluated, no significant difference was found in terms of re-admission to the emergency department and the frequency of hospitalization. (Respectively, within seven days p=0.738, 0.805, within thirty days p=0.130, 0.697). In the patient group with plasma glucose level of 200 mg/dl and above, waiting times in the emergency department (p= 0.012) and average fluid replacement were higher (p=0.002). As the factors affecting re-admission were evaluated, it was found significant that the patient had insulin-dependent diabetes. (Within in seven days OR:2.20, %95 GA 1,.26-3.84, p = 0.005; within thirty days OR:2.48, %95 GA 1.39-4.41, p = 0.002). Other factors such as gender, age, admission glucose level and diabetes type were not found to be effective.

Conclusions

The high blood glucose level of diabetic non-complicated hyperglycemia cases admitted to the emergency department was not found to have an effect on recurrent admissions and hospitalizations for any reason in the first seven and thirty days. Treatment and follow-up planning should be done carefully in insulin-dependent diabetic patients with a high probability of re-admission and hospitalization in this group

Hyperglycemia and diabetes mellitus (DM)-related emergencies constitute approximately 1% of all admissions to the emergency department [1]. With or without an additional disease, hyperglycemia is frequently detected in the emergency department [2].

Although DM is a chronic disease, it has acute and life-threatening complications. This includes diabetic ketoacidosis (DKA), hyperosmolar hyperglycemic state (HHS), and hypoglycemia [3]. Acute complications such as DKA and HHS are not seen in the majority of the patient population presenting to the emergency department [4]. Controlling hyperglycemia is important for the patients in the emergency department for whom hospitalization is planned. It is known that hyperglycemia is a poor prognostic factor associated with many diseases in the hospitalized patient group [5]. It is known that controlling hyperglycemia in the long term reduces the chronic complications of diabetes, but there is no clear treatment recommendation for non-complicated patients who are considered to be discharged from the emergency department. Hydration or treatments applied to lower blood sugar in this patient group without acute diabetic complications vary among physicians and there is no common treatment recommendation [6].

It is controversial whether there is any benefit in lowering blood glucose levels to a certain glucose level in the emergency room in patients with a diagnosis of DM who were diagnosed with hyperglycemia in the emergency department and who did not develop DKA or HHS, an acute complication of diabetes. It is already known that short-acting crystalline insulin, which can be used in treatment, will not be beneficial in the long term. It is thought that the reason for the treatments to reduce the blood glucose level in the emergency department is to prevent the development of short-term complications of hyperglycemia such as diabetic ketoacidosis, but this issue is open to discussion. Considering the fact that hyperglycemia treatment in the emergency department of patients who applied with hyperglycemia without acute complications does not contribute positively to the management of diabetes in the short term, as well as possible complications of insulin therapy to be applied, it would be more appropriate to provide appropriate outpatient follow-up after admission for long-term treatment [7].

Study population

The primary aim of the study was to reveal the frequency and determinants of adverse events in patients with DM who were admitted to the emergency department for any reason and decided for outpatient treatment.

All diabetic patients over the age of 18 who applied to the emergency department were included in the prospective, cross-sectional study performed in the emergency department of a tertiary education hospital with approximately 100,000 patient admissions per year following the approval of the regional ethics committee. Patients who were admitted to the emergency department due to diabetes-related hyperglycemic complications (acute or chronic) or for an independent reason, and patients who presented with hypoglycemia were excluded from the study. During the study, the first application of the patients with the same complaint was accepted as index application.

Data collection

Demographic data, complaints, plasma blood glucose levels at admission, parenteral fluids if applied, development of iatrogenic hypoglycemia in the emergency department, outcome, and duration of stay in the emergency room of diabetic patients who applied to the emergency department with any complaint were recorded by the physician who provided the care of the patient. The examinations performed in all patients who were discharged in their usual care in the emergency room were checked again by the researcher from the hospital information management system.

Patients with a glucose level above 250 mg/dl and a positive urine ketone and a serum bicarbonate level below 18 mEq/L in the emergency department, patients with DKA, a glucose level above 600 mg/dl and in the absence of ketoacidosis (Ph > 7.30), serum osmolality of 320 mOsm/kg was considered as hyperosmolar HHS. Patients with a glucose level of 60 mg/dl or less in the emergency department or patients with dextrose-responsive hypoglycemia symptoms with a glucose level of 100 mg/dl or less were considered iatrogenic hypoglycemia [8]. Patients diagnosed with DKA, HHS and hypoglycemia were excluded from the study.

On the 7th and 30th days after discharge from the emergency room, all patients were contacted by phone as well as the hospital registration system, and their admissions and hospitalizations for any reason other than trauma were learned and recorded. The primary outcome criteria of the study were admission to hospital or admission to hospital for any reason within 7 and 30 days.

Statistical Analysis and Sampling

In the literature, the rate of patients with a diagnosis of diabetes who applied to the emergency service over the age of 18 is reported as 9.4% (1). The rate of re-admission of DM patients who applied to our emergency department is known to be 9.2% in our previous studies [9]. The sample size was determined for the 95% confidence interval, alpha 0.05, and 80% study power for the 10% expected clinical contribution. In the evaluation, categorical data were recorded with range and percentage frequency, data obtained by measurement were recorded with range, mean and standard deviation data. The glucose level was accepted as the primary independent predictor reference. Logistic regression analysis was used to evaluate the effect of diabetes type, insulin-dependent diabetes mellitus, age, and gender on primary outcome, as well as the primary independent predictor glucose level.

Patients

During the study, 342 patients were included in the study. 49 (14.3%) patients presented to the emergency department repeatedly, 6 (1.7%) patients had missing data, 5 (1.4%) patients had hypoglycemia as the main complaint, 9 (2.6%) patients had diabetic acute complications and 44 (12.8%) was excluded because the patient was admitted to the emergency department for other reasons. Of the 229 patients included in the study, 93 (40.6%) were re-admitted to hospital within 7 days and 126 within 30 days. 21 of these patients were hospitalized within 7 days and 24 (10.4%) within 30 days (Fig. 1).

Clinical Outcomes

Of the patients, 126 (55%) were female, and the mean age was 58.9 (± 12.6) years. Twenty-seven (11.8%) of the cases declared that they had type 1 diabetes, 79 patients (34.5%) were using insulin. A total of 103 (45%) patients received fluid replacement (Mean Glucose: 254.7 mg/dl ± 122.6), and 14 (6.1%) patients received crystallized short-acting insulin therapy (Mean Glucose: 416.5 mg/dl ± 72.3). It was determined that iatrogenic hypoglycemia did not develop in any of the patients during the study. The mean length of stay in the emergency department was found to be 145.3 minutes (± 109.1).

The mean duration of stay in the emergency department is 165.1 min (± 109.3) for patients with plasma glucose level of 200 mg/dl and above, and 128.9 minutes (± 106.6) for patients with a plasma glucose level of less than 200 mg/dl. Mean waiting times in the emergency department were significantly higher (p = 0.012, 95% CI 7.9–64.5). Similarly, mean fluid replacement was higher in the group with plasma glucose levels above 200 mg/dl (p = 0.002, 95% CI 121.6-521.6) (Table 1).

When re-admissions and hospitalizations within 7 and 30 days were examined, no significant difference was found in admission plasma glucose levels (Table 2).

Table 1

Mean residence times and fluid replacements according to blood glucose level. *95%CI: 95% Confidence interval
	Groups < 200 mg/dl ≥200 mg/dl		p	%95 GA*
Time of stay in the emergency room	128.9 dk (± 106.6)	165.1 dk, (± 109.3)	0.012	7.9–64.5
Fluid replacement administered	450.0 ml (± 500.1)	771.6 ml (± 509.1)	0.002	121.6-521.6

Table 2

Admission glucose levels according to admission and hospitalization at seven and thirty days
		Glucose level in admission (mg/dl)
Application in 7 days	Yes	223.8 ± 118.3
Application in 7 days	No	209.1 ± 96.5
Hospitalization in 7 days	Yes	212.9 ± 107.3
Hospitalization in 7 days	No	215.3 ± 106.0
Application in 30 days	Yes	215.6 ± 111.3
Application in 30 days	No	214.5 ± 99.6
Hospitalization in 30 days	Yes	212.7 ± 114.8
Hospitalization in 30 days	No	215.4 ± 105.1

Insulin-dependent diabetes mellitus (OR:2.62 95% CI 1.39–4.93 p = 0.003) in the logistic regression model (p = 0.032) created to determine the factors affecting the recurrent presentation of diabetic patients admitted to the emergency department within the first seven days after admission.) was found to be the only significant factor. Other factors other than this; gender (p = 0.134 OR 1.51, 95% CI 0.87–2.62), age (p = 0.583, OR 0.85, 95% CI 0.48–1.51), glucose level at admission (p = 0.227, OR 0.70, 95% CI 0.39–1.24) and diabetes type 1 (p = 0.373 OR: 0.66 95% CI 0.27–1.63) were not effective (Fig. 2).

When we evaluated the outcomes of re-admission to the emergency department and hospitalization separately according to insulin-dependent DM, it was found that the frequency of admission within 7 and 30 days and hospitalization within 7 days increased significantly in insulin-dependent patients (Table 3).

Table 3

Frequency of re-admission and hospitalization within 7 and 30 days. *Pearson Chi-Square
Yes/No n (%)	Insulin dependent	Non-insulin dependent	P*	OR (%95 GA)
7-day application	42 / 37 (%53)	51/99 (%34)	P = 0.005	2.20 (1.26–3.84)
7-day hospitalization	12/67 (%15.2)	9/141 (%6)	P = 0.022	2.80 (1.12–6.98)
30-day application	55/24 (%69.6)	72/78 (%48)	P = 0.002	2.48 (1.39–4.41)
30-day hospitalization	12/67 (%15.2)	12/138 (%8.0)	P = 0.091	2.06 (0.87–4.48)

When patients who applied to the emergency department with diabetic complications were examined, it was shown in a retrospective study that the rate of admission to the emergency department within 14 days was 17% [10]. In our prospective study, it was found that this rate was 40.6% for the first 7 days, when all hospital admissions (including the outpatient clinic) were taken into account. The 30-day hospitalization rate was 229/24 (10.4%), which was similar to previous studies [10]. There are studies showing that reducing the frequency of recurrent emergency department admissions can be reduced with accessible special diabetes follow-up programs, and it would be beneficial to include all diabetic patients discharged from the emergency department in such family medicine or endocrinology programs [11].

When the factors affecting the recurrent presentation of diabetic patients who applied to the emergency department in the first 7 and 30 days after admission were examined, it was found that only the patient's insulin-dependent DM was significant. In the study of Yan et al., which included emergency room patients with diagnosis of acute complications due to diabetes, it was found that the patients' use of insulin was significant for re-admission within 30 days [12]. In another cohort study, diabetic patients who applied to the emergency department with blood glucose levels over 400 mg/dl were examined and, in line with our study, no correlation was found between re-admission for any reason and elevated plasma glucose levels. In their studies, age, gender, insulin dependence and DM type were not included in the evaluation, and the relationship between basic laboratory tests and fluid or insulin replacement in the emergency room and recurrent admissions was examined and no relationship could be established [8].

When we examined the age factor alone, unlike a systematic review in which the frequency of adverse events in diabetic patients was evaluated in the emergency department, no statistical difference was found in the re-admission rates in our study, even in the non-complicated hyperglycemic population aged 65 and over [13]. Similarly, it was seen that there was no statistical effect as a factor in the binary logistic regression analysis.

In a study conducted in young adults, the rate of 30-day re-admission and hospitalization was higher for type 1 diabetes than type 2 diabetes [14]. Although we think that this is due to the low incidence of type 2 diabetes in young adults, in our study, when diabetes type (type 1–2) was examined as an independent factor in all patients aged 18 years and older, we found that it was not a determining factor in re-admission.

In our study, the length of stay in the emergency room and the fluid replacement administered were statistically significantly higher in patients with blood glucose levels above 200 mg/dl. It has been shown that lowering blood sugar with insulin therapy has no effect on the duration of stay in the emergency department in patients who are not considered to have diabetic acute complications and have high blood glucose levels [15]. However, in the study of Driver et al., it was also found that each 1 liter of intravenous fluid replacement therapy prolongs the stay in the emergency room by 45 minutes [16]. In the study conducted by Johnson-Clague et al., one of the studies on the duration of stay in the emergency room and hospitalization of hyperglycemic patients, and including all patients with admission blood glucose levels above 200 mg/dl, it was found that reducing blood glucose level below 200 mg/dl in the emergency department resulted in a reduction in the total hospitalization rate (in hospitalized patients). It was emphasized that it did not change the length of stay [17]. Prolongation of waiting times in the emergency department is one of the factors that increases the emergency department crowd and reduces the quality of patient care [18].

In this study, we found that none of the factors of age, gender, and diabetes type we examined, as well as blood glucose level at admission, were predictive of re-admission and hospitalization. In addition, in our study, the frequency of re-admission and hospitalization within 7 days and the frequency of re-admissions within 30 days increased in patients with insulin-dependent DM.

In non-complicated hyperglycemia cases in the emergency department, the application plasma glucose level is not effective in recurrent admissions. In addition, considering the finding that the fluid replacement decision prolongs the length of stay in the emergency room and possible complications of insulin administration, traditional methods (insulin and fluid therapy) should be reviewed in cases of non-complicated hyperglycemia, and patient management and follow-up should be more meticulous, especially in the emergency department admissions of insulin-dependent diabetic patients can be said.

This study has some limitations; first of all, it is most important that it was performed in a single center with a limited number of patients. In addition, although the patients were recruited prospectively, the treatments given were left to the preference of the physicians and no randomization was performed. Randomized controlled studies are needed to more clearly demonstrate the effectiveness of plasma glucose-lowering therapy given in the emergency department.

Funding

This study was not funded.

Declaration of Competing Interest

All authors have no conflicts of interest.

Ethical approval and ethical number provided by the review board
No:374 Date: 14.06.2017

Consent to Participate

Informed consent is applicable for this study.

Consent for Publication

Not applicable

Availability of data and material

Data and materials are available

Code Availability

Not applicable

Author Contributions: Conceptualization; Murat DUYAN (MD), Aslıhan Yürüktümen Ünal(AYÜ), MD., Prof; Data curation; Ertuğ Günsoy(EG), MD, Fatma Selman(FS), MD; Formal analysis; FS, EG, MD; Funding acquisition; EG; Investigation; EG, AAS; Methodology; FS, MD, AS; Project administration; AYÜ, AS; Resources; AYÜ, FS; Software; MD, EG; Supervision; AYÜ; Validation; AYÜ, EG; Visualization; FS, MD; Roles/Writing - original draft; MD, FS; Writing - review & editing; EG, AYÜ.

Acknowledgments: We would like to thank emergency medicine professors Aslıhan Yürüktümen ÜNAL.

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You are reading this latest preprint version

Determinant The Frequency Of Short-Term Undesirable Events In Diabetes Discharged From The Emergency Department

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Abstract

Figures

Introduction

Subjects And Methods

Study population

Data collection

Statistical Analysis and Sampling

Results

Patients

Clinical Outcomes

Discussion

Conclusions

Limitations

Declarations

References

Status:

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