In a 180-day period spanning from late 2017-early 2018, EMS providers from more than 1,000 agencies responded more than 2.5 million times. About 50,000 (2.1 percent) of those calls were diabetic emergencies.
These response statistics, collected from the ESO EMS Index of real-world data, were shared with EMS1 by the ESO data analysis team to continue a discussion about the prehospital assessment and treatment of hypoglycemia, a common consequence of diabetes. Nearly 10 percent of the U.S. population (30.3 million people) has diabetes and an additional 84.1 million adults have prediabetes. Many other health conditions, including hypertension, heart disease, vision loss and mobility impairment, are worsened by diabetes. The total direct and indirect costs attributed to diabetes each year totals $322 billion.
Should EMTs use glucagon more often?
In early 2018, Harvard Medical School researchers, using a letter published in the “Annals of Internal Medicine,” argued for increased access to and use of glucagon by EMTs. The study findings were based on glucagon administration data from the National EMS Information System and glucagon prescribing frequency using Medicare Part D information.
The research methods and findings took a narrow look at the prehospital care of hypoglycemia – igniting a vigorous debate among EMS providers. Glucagon is a treatment for hypoglycemia, but it’s not the only treatment. Hypoglycemia is somewhat unique among prehospital emergencies because it has multiple EMT treatment options, including:
- Encouraging the patient to eat his or her own food.
- Administering the patient oral glucose.
- Monitoring the patient’s airway and breathing while waiting for paramedics to arrive.
In addition to those treatments, ALS providers can administer dextrose and glucagon. Hypoglycemia treatment is not a binary choice of glucagon or nothing.
After writing, “Yes, EMTs can administer glucagon,” I asked ESO for EMS Index data on diabetic patient encounters, utilization of different treatments and if glucagon is a regularly or rarely used prehospital treatment for hypoglycemia.
How frequently is diabetes the EMS primary impression?
Hypoglycemic patients were identified by searching the dataset by EMS provider primary impression, which is the provider’s field diagnosis. The two primary impressions used to filter the dataset were:
- Diabetic hypoglycemia and diabetic symptoms.
- Diabetic hypoglycemia.
As you review the data, keep in mind that “diabetic symptoms” may include hyperglycemic and diabetic ketoacidosis (DKA) patients.
| Primary Impression | Number of Calls | Percent of Calls |
|---|---|---|
| Diabetic hypoglycemia and diabetic symptoms | 26,577 | 1.1 percent |
| Diabetic hypoglycemia | 23,965 | 1 percent |
| Total | 50,452 | 2.1 percent |
In 180 days, there were 2,511,430 calls for service. Just over 50,000 of these calls were for a diabetic emergency. How does that percentage, 2.1 percent, compare to your department’s number of responses for diabetic emergencies?
How frequently is a blood glucose level checked by EMS?
Assessing the patient’s blood sugar level with a glucometer is a widely accepted patient assessment practice and part of the National EMS Education Standards for AEMTs and paramedics. Some states, including Wisconsin, New York and Pennsylvania, authorize EMTs to conduct blood glucose monitoring.
| Primary Impression | Blood Glucose Checked | BG Checked Percent |
|---|---|---|
| Diabetic hypoglycemia and diabetic symptoms | 22,320 | 84 percent |
| Diabetic hypoglycemia | 20,744 | 87 percent |
| Total | 43,064 | 85 percent |
Blood glucose level, along with patient history and mental status, are critical to making a field diagnosis of hypoglycemia and a treatment decision. It’s both reassuring that 85 percent of patients had their blood sugar level documented and worrisome that 15 percent didn’t have a blood sugar level recorded.
For the patients who had a blood sugar checked, 78 percent (33,709) of all patients had a blood sugar level less than 60 mg/dL. There was little difference in blood sugar level based on the primary impression – 77 percent (17,321) “diabetic hypoglycemia and diabetic symptoms” patients and 79 percent (16,478) “diabetic hypoglycemia.”
It’s plausible that for some patients, a family member, a friend, another caregiver or even the patient assessed the patient’s blood sugar before EMS arrived. And that number, along with patient SAMPLE history, was used to determine treatment with oral glucose, intravenous dextrose or glucagon. What percentage of diabetic patients in your service have a blood glucose level documented in the ePCR?
Which prehospital hypoglycemia treatment is used most often?
Primary impression, scope of practice and protocols determine the prehospital treatment for hypoglycemia by EMTs and paramedics. Those treatments include:
- Oral glucose.
- Intravenous dextrose.
- Intramuscular glucagon.
Patients who received a hypoglycemia treatment are shown in this table. Keep in mind that some patients may have received more than one treatment.
| Primary Impression | Oral Glucose | IV Dextrose | IM Glucagon |
|---|---|---|---|
| Diabetic hypoglycemia and diabetic symptoms | 19 percent; 5,161 | 46 percent; 12,178 | 7 percent; 1,736 |
| Diabetic hypoglycemia | 20 percent; 4,882 | 48 percent; 11,659 | 7 percent; 1,655 |
| Total | 20 percent; 10,043 | 47 percent; 23,837 | 7 percent; 3,391 |
A quarter of the patients with a diabetic emergency did not have a treatment of oral glucose, dextrose or glucagon documented. It’s possible the 26 percent of patients with a primary impression of a diabetic emergency were mostly the 22 percent of patients who did not have a blood glucose level below 60 mg/dL.
How often are patients transported after hypoglycemia treatment?
Hypoglycemia is one of the patient encounters that often concludes with a non-transport after on-scene treatment. In this dataset of 50,000 diabetic emergency calls (2.1 percent of 2.5 million patient encounters), just over half of patients were transported after on-scene treatment.
| Primary Impression | Treatment after Transport |
|---|---|
| Diabetic hypoglycemia and diabetic symptoms | 56 percent |
| Diabetic hypoglycemia | 58 percent |
| Total | Not provided |
The decision to not transport a patient after treatment of hypoglycemia should be based on reassessment of:
- Patient’s blood sugar level after treatment.
- Patient’s mental status and capability for self-care and monitoring.
- Presence of friends and family capable of and willing to monitor patient.
- Local protocols allowing non-transport after on-scene treatment.
- Documentation of non-transport within the ePCR or as an addendum.
Top takeaways for EMS quality assurance and clinical monitoring
After reviewing and summarizing the data provided by ESO, here are my top three takeaways on prehospital care of hypoglycemia.
1. Your dataset might not be big enough
An EMS service with 2,500 patient calls per year – 1,000th of the total data set – might see less than 100 diabetic patients in a year. That number of patient encounters isn’t likely significant enough to meaningfully analyze the appropriateness of providers’ primary impression or treatment decision. Using datasets like the EMS Index or NEMSIS, which aggregate data across thousands or tens of thousands of agencies, is an opportunity for educators, field providers and quality improvement coordinators to set clinical benchmarks and compare their current practice of care to a large cohort of agencies.
2. Remediation may (or may not) be needed
It’d be easy to boldly proclaim, “We’re going to check blood sugar on 100 percent of diabetic patients,” but that might not make sense based on the information available to the EMS providers at the time of patient assessment. Eighty-five percent of patients getting a blood sugar check might be an exceptional number and the effort to increase that to 86 percent could be resource intensive and moral zapping. Make sure you know what a good clinical practice is before you aim for perfect through remediation and protocol updates.
3. Want to know something, ask the questions
There is no shortage of data in EMS. Every patient encounter produces hundreds or thousands of data points in the CAD and ePCR systems. The real challenge is finding sources of aggregated data, filtering the data and finding meaning in the data.
The NEMSIS dataset, used by the Harvard Medical School researchers who were advocating for glucagon (and by Nick Nudell and myself when we wanted to know if Halloween is really the most dangerous day of the year for children), is freely available for anyone to search and filter. Exploring your department’s CAD and ePCR data should be at your fingertips. Ask your vendor for training on how to create filters and generate reports. Also ask your vendor for aggregated, de-identified reports from across all of their customers. Be curious about how your EMS providers’ assessments and treatments compare to other agencies.
What are your top takeaways on hypoglycemia encounters, assessments and treatments? What questions would you like to ask and explore with the EMS Index, NEMSIS or other datasets?
