Davut J. Savaser, MPH

While increasing evidence suggests that hyperglycemia during illness is associated with poor clinical outcome,1, 2 hyperglycemia in the hospital setting is often overlooked and unaddressed.3, 4 Early and intensive management of hyperglycemia may improve outcomes in hospitalized patients.57 Emergency Department (ED) glucose values may present an early opportunity to identify hyperglycemic patients as having unrecognized glucose intolerance and improve early glycemic control for hospitalized patients. Serum glucose values are available for 18% of 110 million annual ED visits in the United States, and many others undergo capillary glucose measurements.8 Although stressors and lack of fasting may contribute to ED hyperglycemia, communication and management should be similar.5 In this study, we hypothesized that in less than 20% of patients ED hyperglycemia would be recognized, communicated to patients, or they would receive ED treatment.

PATIENTS AND METHODS

RESULTS

During the data collection period, 27,688 (58%) ED visits had at least 1 serum glucose result. After excluding multiple glucose results for the same visit, the median glucose value was 106 mg/dL (range, 7‐2280 mg/dL); 3517 (13%) values were 140‐199 mg/dL, and 2304 (8%) values were 200 mg/dL. We located 385 of the 400 (96%) randomly selected charts. Interrater agreement for chart review was high (kappa = 0.91‐0.98).

Table 1 shows demographic characteristics and Table 2 shows clinical data of the sample, stratified by glucose group and charted diagnosis of diabetes. Overall, 55% of patients with glucose values 140‐199 mg/dL and 16% of patients with glucose 200 mg/dL had no prior diabetes diagnosis. Hyperglycemia was associated with sepsis for 22% of patients, infection without sepsis for 13% of patients, and traumatic injury for 19% of patients.

No patient received intravenous fluids with dextrose prior to initial serum glucose determination, and there was no difference in home corticosteroid use between groups (P = 0.23). Patients with known diabetes were more likely to receive insulin in the ED (P < 0.01). Only 1 patient received an oral hypoglycemic agent in the ED. Three patients had documented hypoglycemia on capillary blood glucose during the ED stay, and no patients had hypoglycemia based on serum glucose during the ED or hospital stay. Among hospitalized patients, 61% had inpatient orders for diabetic‐consistent/carbohydrate‐consistent diet, 65% for capillary glucose tests daily, and 63% for sliding scale insulin.

We also present written discharge instructions data for 363 visits (253 inpatient and 110 ED) in Table 2; discharge instructions were not available for 22 visits (12 deaths during hospitalization, 10 missing instructions). New antidiabetic medications were prescribed for 42 (12%) patients, all from the inpatient setting. There was no difference between inpatient and ED communication of hyperglycemia (10% [95%CI, 7%‐14%] versus 9% [95%CI, 4%‐15%]) and recommendation for further outpatient testing (8% [95%CI, 4%‐11%] versus 4% [95%CI, 0%‐7%]) in written discharge instructions (P = 0.73 and 0.16, respectively). Compared to those with glucose 140‐199 mg/dL, patients with glucose 200 mg/dL were more likely to receive written communication of hyperglycemia (17% [95%CI, 11%‐22%] versus 3% [95%CI, 0%‐6%]) and recommendation for further outpatient testing (10% [95%CI, 6%‐14%] versus 3% [95%CI, 0%‐5%] (both, P < 0.01).

DISCUSSION

Although noncritical ED glucose values may be overlooked, values sufficient to motivate inpatient and long‐term management are sometimes uncovered, and when unrecognized may be missed opportunities. Indeed, admission hyperglycemia has been linked to poor clinical outcomes in hospitalized patients for a variety of conditions, particularly for myocardial infarction, stroke, and critical illness.1215

In this study, we evaluated recognition, communication, and management of ED glucose values above a relatively conservative threshold of 140 mg/dL, occurring in 21% of ED glucose results. Diabetes screening thresholds for casual glucose values as low as 120 mg/dL,9 and intensive glycemic control in critically ill patients to a target as low as 110 mg/dL have been suggested.5 Nevertheless, only 16% of our sample received insulin in the ED for hyperglycemia, and hyperglycemia was charted as a diagnosis in only 9% of cases.

This is especially important because 77% of ED visits without hyperglycemia charted as a diagnosis resulted in hospitalization, and early glycemic control was infrequently initiated. Limited ED management of hyperglycemia may be driven by the presence of more critical management issues (eg, 54% of patients had concomitant infection or trauma), lack of familiarity with guidelines, which suggest treatment to glucose <140 mg/dL in critically ill patients and <180 mg/dL in all hospitalized patients,16 or fear of adverse events, such as hypoglycemia. Additionally, ED crowding has been shown to effect decreased quality and timeliness of treatment for pneumonia, and may have similar effects for hyperglycemia.17 Inpatient recognition of hyperglycemia, based on orders for diet, glucose checks, and insulin, appeared significantly better, but this did not translate to improved communication in written discharge instructions. Additionally, many hospitalized patients may spend many hours, or even days, in the ED waiting for beds, which currently is a missed opportunity to initiate early therapy.

Written discharge instructions informed less than 10% of patients of their hyperglycemia or outlined a plan for further evaluation and management. Our prior work suggests that nearly all (95%) ED patients want to be informed of elevated blood glucose and are willing to follow‐up, if instructed.18 The current data suggests that hyperglycemia in ED and hospitalized patients is frequently unrecognized and undertreated, and opportunities to institute an outpatient plan to address hyperglycemia are frequently missed.

This study has several potential limitations. This study was performed at a single academic center, which limits generalizability to other geographic areas and hospital types. Accuracy of abstracted data depended on chart review, which is limited by the possibility of missing, incomplete, or unreliable information. Standardized definitions and abstraction forms limited potential for bias, and high interrater agreement demonstrated internal reliability of the chart review. We considered only initial glucose values and were unable to determine nutritional status; it is possible that subsequent measurements were within an acceptable range. Conversely, hospitalized patients may have developed hyperglycemia subsequent to the initial glucose result, which would underestimate the scope of inpatient hyperglycemia. Also, because there are limited data for interpretation of ED hyperglycemia, we were unable to determine optimal glucose thresholds. Finally, we were unable to evaluate the content of verbal instructions or letters to outpatient providers, which limited our ability to fully describe communication of abnormal findings. However, patients do not often retain information in verbal instructions, in the context of new diagnoses and complex medical regimens.

In summary, recognition, management, and communication of ED hyperglycemia were suboptimal in our patient population and represent a missed opportunity. Enhanced recognition, management, and referral for hyperglycemia observed during usual ED care may provide an unobtrusive method to improve identification of undiagnosed diabetes/prediabetes and initiation of intensive glycemic control for hospitalized patients.

While increasing evidence suggests that hyperglycemia during illness is associated with poor clinical outcome,1, 2 hyperglycemia in the hospital setting is often overlooked and unaddressed.3, 4 Early and intensive management of hyperglycemia may improve outcomes in hospitalized patients.57 Emergency Department (ED) glucose values may present an early opportunity to identify hyperglycemic patients as having unrecognized glucose intolerance and improve early glycemic control for hospitalized patients. Serum glucose values are available for 18% of 110 million annual ED visits in the United States, and many others undergo capillary glucose measurements.8 Although stressors and lack of fasting may contribute to ED hyperglycemia, communication and management should be similar.5 In this study, we hypothesized that in less than 20% of patients ED hyperglycemia would be recognized, communicated to patients, or they would receive ED treatment.

PATIENTS AND METHODS

RESULTS

During the data collection period, 27,688 (58%) ED visits had at least 1 serum glucose result. After excluding multiple glucose results for the same visit, the median glucose value was 106 mg/dL (range, 7‐2280 mg/dL); 3517 (13%) values were 140‐199 mg/dL, and 2304 (8%) values were 200 mg/dL. We located 385 of the 400 (96%) randomly selected charts. Interrater agreement for chart review was high (kappa = 0.91‐0.98).

Table 1 shows demographic characteristics and Table 2 shows clinical data of the sample, stratified by glucose group and charted diagnosis of diabetes. Overall, 55% of patients with glucose values 140‐199 mg/dL and 16% of patients with glucose 200 mg/dL had no prior diabetes diagnosis. Hyperglycemia was associated with sepsis for 22% of patients, infection without sepsis for 13% of patients, and traumatic injury for 19% of patients.

No patient received intravenous fluids with dextrose prior to initial serum glucose determination, and there was no difference in home corticosteroid use between groups (P = 0.23). Patients with known diabetes were more likely to receive insulin in the ED (P < 0.01). Only 1 patient received an oral hypoglycemic agent in the ED. Three patients had documented hypoglycemia on capillary blood glucose during the ED stay, and no patients had hypoglycemia based on serum glucose during the ED or hospital stay. Among hospitalized patients, 61% had inpatient orders for diabetic‐consistent/carbohydrate‐consistent diet, 65% for capillary glucose tests daily, and 63% for sliding scale insulin.

We also present written discharge instructions data for 363 visits (253 inpatient and 110 ED) in Table 2; discharge instructions were not available for 22 visits (12 deaths during hospitalization, 10 missing instructions). New antidiabetic medications were prescribed for 42 (12%) patients, all from the inpatient setting. There was no difference between inpatient and ED communication of hyperglycemia (10% [95%CI, 7%‐14%] versus 9% [95%CI, 4%‐15%]) and recommendation for further outpatient testing (8% [95%CI, 4%‐11%] versus 4% [95%CI, 0%‐7%]) in written discharge instructions (P = 0.73 and 0.16, respectively). Compared to those with glucose 140‐199 mg/dL, patients with glucose 200 mg/dL were more likely to receive written communication of hyperglycemia (17% [95%CI, 11%‐22%] versus 3% [95%CI, 0%‐6%]) and recommendation for further outpatient testing (10% [95%CI, 6%‐14%] versus 3% [95%CI, 0%‐5%] (both, P < 0.01).

DISCUSSION

Although noncritical ED glucose values may be overlooked, values sufficient to motivate inpatient and long‐term management are sometimes uncovered, and when unrecognized may be missed opportunities. Indeed, admission hyperglycemia has been linked to poor clinical outcomes in hospitalized patients for a variety of conditions, particularly for myocardial infarction, stroke, and critical illness.1215

In this study, we evaluated recognition, communication, and management of ED glucose values above a relatively conservative threshold of 140 mg/dL, occurring in 21% of ED glucose results. Diabetes screening thresholds for casual glucose values as low as 120 mg/dL,9 and intensive glycemic control in critically ill patients to a target as low as 110 mg/dL have been suggested.5 Nevertheless, only 16% of our sample received insulin in the ED for hyperglycemia, and hyperglycemia was charted as a diagnosis in only 9% of cases.

This is especially important because 77% of ED visits without hyperglycemia charted as a diagnosis resulted in hospitalization, and early glycemic control was infrequently initiated. Limited ED management of hyperglycemia may be driven by the presence of more critical management issues (eg, 54% of patients had concomitant infection or trauma), lack of familiarity with guidelines, which suggest treatment to glucose <140 mg/dL in critically ill patients and <180 mg/dL in all hospitalized patients,16 or fear of adverse events, such as hypoglycemia. Additionally, ED crowding has been shown to effect decreased quality and timeliness of treatment for pneumonia, and may have similar effects for hyperglycemia.17 Inpatient recognition of hyperglycemia, based on orders for diet, glucose checks, and insulin, appeared significantly better, but this did not translate to improved communication in written discharge instructions. Additionally, many hospitalized patients may spend many hours, or even days, in the ED waiting for beds, which currently is a missed opportunity to initiate early therapy.

Written discharge instructions informed less than 10% of patients of their hyperglycemia or outlined a plan for further evaluation and management. Our prior work suggests that nearly all (95%) ED patients want to be informed of elevated blood glucose and are willing to follow‐up, if instructed.18 The current data suggests that hyperglycemia in ED and hospitalized patients is frequently unrecognized and undertreated, and opportunities to institute an outpatient plan to address hyperglycemia are frequently missed.

This study has several potential limitations. This study was performed at a single academic center, which limits generalizability to other geographic areas and hospital types. Accuracy of abstracted data depended on chart review, which is limited by the possibility of missing, incomplete, or unreliable information. Standardized definitions and abstraction forms limited potential for bias, and high interrater agreement demonstrated internal reliability of the chart review. We considered only initial glucose values and were unable to determine nutritional status; it is possible that subsequent measurements were within an acceptable range. Conversely, hospitalized patients may have developed hyperglycemia subsequent to the initial glucose result, which would underestimate the scope of inpatient hyperglycemia. Also, because there are limited data for interpretation of ED hyperglycemia, we were unable to determine optimal glucose thresholds. Finally, we were unable to evaluate the content of verbal instructions or letters to outpatient providers, which limited our ability to fully describe communication of abnormal findings. However, patients do not often retain information in verbal instructions, in the context of new diagnoses and complex medical regimens.

In summary, recognition, management, and communication of ED hyperglycemia were suboptimal in our patient population and represent a missed opportunity. Enhanced recognition, management, and referral for hyperglycemia observed during usual ED care may provide an unobtrusive method to improve identification of undiagnosed diabetes/prediabetes and initiation of intensive glycemic control for hospitalized patients.

While increasing evidence suggests that hyperglycemia during illness is associated with poor clinical outcome,1, 2 hyperglycemia in the hospital setting is often overlooked and unaddressed.3, 4 Early and intensive management of hyperglycemia may improve outcomes in hospitalized patients.57 Emergency Department (ED) glucose values may present an early opportunity to identify hyperglycemic patients as having unrecognized glucose intolerance and improve early glycemic control for hospitalized patients. Serum glucose values are available for 18% of 110 million annual ED visits in the United States, and many others undergo capillary glucose measurements.8 Although stressors and lack of fasting may contribute to ED hyperglycemia, communication and management should be similar.5 In this study, we hypothesized that in less than 20% of patients ED hyperglycemia would be recognized, communicated to patients, or they would receive ED treatment.

PATIENTS AND METHODS

RESULTS

During the data collection period, 27,688 (58%) ED visits had at least 1 serum glucose result. After excluding multiple glucose results for the same visit, the median glucose value was 106 mg/dL (range, 7‐2280 mg/dL); 3517 (13%) values were 140‐199 mg/dL, and 2304 (8%) values were 200 mg/dL. We located 385 of the 400 (96%) randomly selected charts. Interrater agreement for chart review was high (kappa = 0.91‐0.98).

Table 1 shows demographic characteristics and Table 2 shows clinical data of the sample, stratified by glucose group and charted diagnosis of diabetes. Overall, 55% of patients with glucose values 140‐199 mg/dL and 16% of patients with glucose 200 mg/dL had no prior diabetes diagnosis. Hyperglycemia was associated with sepsis for 22% of patients, infection without sepsis for 13% of patients, and traumatic injury for 19% of patients.

No patient received intravenous fluids with dextrose prior to initial serum glucose determination, and there was no difference in home corticosteroid use between groups (P = 0.23). Patients with known diabetes were more likely to receive insulin in the ED (P < 0.01). Only 1 patient received an oral hypoglycemic agent in the ED. Three patients had documented hypoglycemia on capillary blood glucose during the ED stay, and no patients had hypoglycemia based on serum glucose during the ED or hospital stay. Among hospitalized patients, 61% had inpatient orders for diabetic‐consistent/carbohydrate‐consistent diet, 65% for capillary glucose tests daily, and 63% for sliding scale insulin.

We also present written discharge instructions data for 363 visits (253 inpatient and 110 ED) in Table 2; discharge instructions were not available for 22 visits (12 deaths during hospitalization, 10 missing instructions). New antidiabetic medications were prescribed for 42 (12%) patients, all from the inpatient setting. There was no difference between inpatient and ED communication of hyperglycemia (10% [95%CI, 7%‐14%] versus 9% [95%CI, 4%‐15%]) and recommendation for further outpatient testing (8% [95%CI, 4%‐11%] versus 4% [95%CI, 0%‐7%]) in written discharge instructions (P = 0.73 and 0.16, respectively). Compared to those with glucose 140‐199 mg/dL, patients with glucose 200 mg/dL were more likely to receive written communication of hyperglycemia (17% [95%CI, 11%‐22%] versus 3% [95%CI, 0%‐6%]) and recommendation for further outpatient testing (10% [95%CI, 6%‐14%] versus 3% [95%CI, 0%‐5%] (both, P < 0.01).

DISCUSSION

Although noncritical ED glucose values may be overlooked, values sufficient to motivate inpatient and long‐term management are sometimes uncovered, and when unrecognized may be missed opportunities. Indeed, admission hyperglycemia has been linked to poor clinical outcomes in hospitalized patients for a variety of conditions, particularly for myocardial infarction, stroke, and critical illness.1215

In this study, we evaluated recognition, communication, and management of ED glucose values above a relatively conservative threshold of 140 mg/dL, occurring in 21% of ED glucose results. Diabetes screening thresholds for casual glucose values as low as 120 mg/dL,9 and intensive glycemic control in critically ill patients to a target as low as 110 mg/dL have been suggested.5 Nevertheless, only 16% of our sample received insulin in the ED for hyperglycemia, and hyperglycemia was charted as a diagnosis in only 9% of cases.

This is especially important because 77% of ED visits without hyperglycemia charted as a diagnosis resulted in hospitalization, and early glycemic control was infrequently initiated. Limited ED management of hyperglycemia may be driven by the presence of more critical management issues (eg, 54% of patients had concomitant infection or trauma), lack of familiarity with guidelines, which suggest treatment to glucose <140 mg/dL in critically ill patients and <180 mg/dL in all hospitalized patients,16 or fear of adverse events, such as hypoglycemia. Additionally, ED crowding has been shown to effect decreased quality and timeliness of treatment for pneumonia, and may have similar effects for hyperglycemia.17 Inpatient recognition of hyperglycemia, based on orders for diet, glucose checks, and insulin, appeared significantly better, but this did not translate to improved communication in written discharge instructions. Additionally, many hospitalized patients may spend many hours, or even days, in the ED waiting for beds, which currently is a missed opportunity to initiate early therapy.

Written discharge instructions informed less than 10% of patients of their hyperglycemia or outlined a plan for further evaluation and management. Our prior work suggests that nearly all (95%) ED patients want to be informed of elevated blood glucose and are willing to follow‐up, if instructed.18 The current data suggests that hyperglycemia in ED and hospitalized patients is frequently unrecognized and undertreated, and opportunities to institute an outpatient plan to address hyperglycemia are frequently missed.

This study has several potential limitations. This study was performed at a single academic center, which limits generalizability to other geographic areas and hospital types. Accuracy of abstracted data depended on chart review, which is limited by the possibility of missing, incomplete, or unreliable information. Standardized definitions and abstraction forms limited potential for bias, and high interrater agreement demonstrated internal reliability of the chart review. We considered only initial glucose values and were unable to determine nutritional status; it is possible that subsequent measurements were within an acceptable range. Conversely, hospitalized patients may have developed hyperglycemia subsequent to the initial glucose result, which would underestimate the scope of inpatient hyperglycemia. Also, because there are limited data for interpretation of ED hyperglycemia, we were unable to determine optimal glucose thresholds. Finally, we were unable to evaluate the content of verbal instructions or letters to outpatient providers, which limited our ability to fully describe communication of abnormal findings. However, patients do not often retain information in verbal instructions, in the context of new diagnoses and complex medical regimens.

In summary, recognition, management, and communication of ED hyperglycemia were suboptimal in our patient population and represent a missed opportunity. Enhanced recognition, management, and referral for hyperglycemia observed during usual ED care may provide an unobtrusive method to improve identification of undiagnosed diabetes/prediabetes and initiation of intensive glycemic control for hospitalized patients.