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Yes, EMTs can administer glucagon

What are the alternative conclusions to a Harvard Medical School examination of glucagon administration in three years of NEMSIS data?


Harvard Medical School researchers analyzed three years of National EMS Information System data and two years of Medicare Part D claims to "suggest that glucagon is underutilized in the prehospital setting and underprescribed in the outpatient setting."

The researchers’ letter to the Annals of Internal Medicine continues with, "Despite its effectiveness, it [glucagon] is not allowed to be administered by most emergency medical services (EMS) personnel; however, family members do so routinely."

“This letter to the editor is not a peer reviewed study,” Mike McEvoy, PhD, NRP, RN, CCRN, said. “If the authors met scientific rigor, they wouldn't have sent it in a letter.  Letters to the editor can say anything.” 
After reading a news article about the data analysis, EMTs across the U.S. have pointed out, correctly, that glucagon is within their scope of practice. (Photo/Greg Friese)
After reading a news article about the data analysis, EMTs across the U.S. have pointed out, correctly, that glucagon is within their scope of practice. (Photo/Greg Friese)
 
“Submit this for peer review and publication, and you’d receive a rejection,” noted McEvoy, the author of the EMS1 Drug Why’s column. “You can’t get past the first paragraph of this letter before you see these authors contradict themselves (glucagon is under-prescribed in the outpatient setting, but families routinely administer it?), have no understanding of EMD (believing that dispatchers somehow check blood sugars over the phone and then fail to code the calls properly), and equate prescribing glucagon to patients to EMS administration.” 
 

Glucagon is an injectable medication administered to patients with hypoglycemia. The medication must be mixed with sterile water, a diluting fluid, before injecting into the patient. Step-by-step instructions, for laypersons and medical professionals, are available on LillyGlucagon.com.

Glucagon releases glucose stored in the patient's liver. An increase in blood sugar can increase a patient's level of consciousness in five to 20 minutes.

Prehospital treatments for hypoglycemia

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 their own food. Who hasn't first encouraged a capable patient to "drink some orange juice and eat a PB&J."
  • Administering oral glucose.
  • Monitoring the patient's airway and breathing while waiting for paramedics to arrive.

Calling additional resources and preparing the patient for those resources to arrive is a viable treatment option for many EMS responses.

EMTs, AEMTs and paramedics assess the patient and then choose the most appropriate treatment. The patient's blood sugar, ability to swallow and mental status are important signs and symptoms for selecting the best course of treatment. Oral glucose might be the best treatment option for basic and advanced providers if a patient is awake enough to follow instructions and swallow a dose of oral glucose.

“Glucometry is a BLS skill. EMTs can check a blood glucose and, if they determine a need to treat, they will,” McEvoy said.  

Patients who are awake, but non-cooperative or who have a decreased level of consciousness – V, P, U on the AVPU scale – need another treatment for their hypoglycemia. Glucagon is an option, as is injected dextrose. In the three-year NEMSIS data set, glucagon was administered on 89,263 calls. At an average price of $212 per glucagon prescription (Medicare Part D claims), this is a not insignificant $18.9 million cost to EMS.

After reading a news article about the data analysis, EMTs across the U.S. have pointed out, correctly, that glucagon is within their scope of practice. However, many EMS personnel, including EMTs, shared that though they are able to administer glucagon, they choose other treatments for hypoglycemic patients.

Why even carry glucagon?

Variability is often a point of pride in EMS and is supported with the quip, "If you have seen one EMS system you have seen on EMS system." The lack of uniform protocols makes it challenging for those of us inside EMS to understand what matters and what doesn't.

"Variability in the Treatment of Prehospital Hypoglycemia: A Structured Review of EMS Protocols in the United States" published in Prehospital Emergency Care in June, 2016 concluded, "In the U.S., EMS protocols for the treatment of hypoglycemia vary significantly. Further studies are warranted to determine the factors underlying this variability and effects on patient outcomes."

Kahn et al conducted some further research and made a conclusion – more glucagon – that may not match the current reality of EMS scope of practice, hypoglycemia treatment protocols and the practice habits developed in different systems. The variability in scope of practice is likely orders of magnitude more perplexing for non-EMS researchers attempting to make sense of our industry and examining why we do the things we do and what, if any, impact those actions have on patient outcomes.

If a medication, like glucagon, is administered relatively infrequently, has a high cost and treats a condition with other viable treatment options, should it continue to be in the scope of many EMTs and remain a required item to stock in every ambulance?

Cheers for EMS research

"Underutilization of Glucagon in the Prehospital Setting" is noteworthy for two primary reasons. First, is the researchers used the NEMSIS database. NEMSIS is the national database that is used to store EMS data from the U.S. states and territories. NEMSIS is a universal standard for how patient care information resulting from an emergency 9-1-1 call for assistance is collected.  

NEMSIS contains tens of millions of records. Yet there is a paucity of research in peer-reviewed publications based on that data. As of May, 2016, only 56 articles were based on NEMSIS data. More research is welcome and needed as EMS continues into its second half century of service.

Second, the examination of NEMSIS records for glucagon utilization was performed by non-EMS physicians. Kahn, Wagner and Gabbay are researchers focused on patients with diabetes and improving the care those patients receive. Their interest in EMS patient care is appreciated and laudable.

Further research and discussion is needed

More research is needed on hypoglycemia and just about every prehospital emergency and treatment. Are you interested in being part of the research effort? Can you answer questions about what works or what doesn't with your service's ePCR data? Have you asked your ePCR vendor to help you query and analyze the data?

NEMSIS research data is a public resource. NEMSIS data helped answer the question, "Is Halloween the most dangerous day for kids?"

What question do you want to answer with the 29,919,652 EMS activations in the 2016 dataset?

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