EmergencyKT: New Onset, Non-DKA Definition: ED patient with newly discovered hyperglycemia, >200 mg % Obtain: CBCD EP1 VBG Serum Ketone Hemoglobin A1c (for follow up) UA β-hcg (female at risk for pregnancy) Asymptomatic Symptomatic Symptomatic Without polydipsia/polyuria (P/P) Polydipsia/polyuria (P/P) Polydipsia/polyuria (P/P) Serum glucose < 250mg % Serum glucose < 400 mg/dl Serum glucose 400-600 mg/dl No admittable or serious Anion Gap < 15 Anion Gap < 15 concomitant illness Creatinine < 1.5 Creatinine < 1.5 No admittable or serious No admittable or serious concomitant illness concomitant illness ED Treatment: ED Treatment: ED Treatment: None 1. 1-2 liters rmal saline 1. 2-3 liters rmal saline 2. 2-5 units Humolog insulin 2. 5-10 units Humolog insulin subcutaneous subcutaneous 3. Recheck EP1 in 1-2 hours 3. Recheck EP1 in 2 hours Disposition: Disposition: Disposition: 1. Brief diabetes education and 1. Glucose<300 mg % (ideally <250) 1. Glucose<300 mg % (ideally <250) diabetes discharge documents 2. Patient competent, good home 2. Patient competent, good home setting setting 2. Follow-up with PCP or urgent 3. Brief diabetes education and 3. Brief diabetes education and medicine clinic <7 days if diabetes discharge documents diabetes discharge documents PCP 4. Start metformin 500 mg. qd 4. Start metformin 500 mg. qd 3. If clinic follow up available 5. Follow-up with PCP or urgent 5. Follow-up with PCP or urgent consider referral to Adele Corbin medicine clinic <7 days if medicine clinic <7 days if (at Hoxworth diabetes clinic) for PCP PCP urgent DM follow up care. 6. Referral to Adele Corbin (at 6. Referral to Adele Corbin (at Call 584-0942 and leave Hoxworth diabetes clinic) for Hoxworth diabetes clinic) for up to date patient contact urgent DM follow up. Call urgent DM follow up. Call information 584-0942 and leave 584-0942 and leave up to date patient contact up to date patient contact information information
EmergencyKT: Use of HbA1c in the Emergency Department What is a Hemoglobin A1c (HbA1c)? HbA1c represents a patient s average glucose level over the last 1-4 months. HbA1c measures the percentage of glycosylated hemoglobin in the blood and thus reflects the average glucose level over the life of a red blood cell (120 days) and the hemoglobin it contains. Because of the constant turning over of red blood cells, more recent glucose levels (ie. the last few weeks) have a greater effect on the HbA1c value than do those from 8 or 12 weeks ago. It is estimated that half of an HbA1c value is attributable to the previous month s glucose level, a further quarter to the month before that, and the other quarter to the two months before that. Since the HbA1c value is t influenced by daily fluctuations in blood glucose concentration, it should t be used to monitor day-to-day blood glucose concentrations and to adjust insulin treatment. Moreover, the HbA1c value may t reflect the day-to-day presence or absence of hyperglycemia and/or hypoglycemia. HbA1c level may be falsely increased in patients with: kidney failure, chronic excessive alcohol intake (Vit B12 and foliate deficiency), untreated iron deficient anemia, and hypertriglyceridemia HbA1c level may be falsely decreased in patients with: acute or chronic blood loss, sickle cell disease, hemolytic anemia/thalassemia. Why obtain an HbA1c in the Emergency Department? Without primary care and proper diabetes management it is extremely difficult for many diabetics to control their glucose levels. It is this lack of glycemic control that is ultimately responsible for the host of debilitating and potentially life threatening health complications associated with poorly controlled diabetes. Diabetic patients who present to the emergency department (and who lack adequate primary care or who are in need of improved diabetes management, education and/or follow up) should have their HbA1c level obtained. The result can then be used to assess the patient s current glycemic control and determine their urgency of needed follow up. The implementation of this tool could significantly reduce the number of unnecessary emergency department visits by decreasing the number of diabetic patients who use the emergency department as a means of obtaining primary care and by decreasing the incidence and severity of diabetic related complications that require emergency department treatment. This also has the potential to reduce costs by decreasing the number of emergency department visits and their related work ups. HbA1c % Average Serum Glucose mg/dl < 5.0 5.4-6.4 6.5-7.0 7.1-8.0 8.1-9.0 9.1-11.9 > 12 < 81 94-127 130-147 150-180 184-214 217-310 > 314 Marginally Kwn Diabetic Increased risk for severe hypoglycemia adverse events including coma, seizures and death Excellently Controlled Well Controlled Take action to lower average glucose levels Note: HbA1c < 8% may be appropriate for patients with a history of severe hypoglycemia, advanced age or severe comorbidities. Poorly Very Poorly Severely Elevated Extremely Poor Management New Onset Hyperglycemia Unlikely (Pre Diabetic) Increased risk for diabetes and diabetes related complications Borderline
Lifetime Benefits and Costs of Intensive Therapy as Practiced in the Control and Complications Trial. The Journal of the American Medical Association. 1996; 17:1409-1415 Ginde AA, Talley BE, Trent SA. Raja AS, Sullivan AF, Camargo CA. Referral of Discharged Emergency Department Patients to Primary and Specialty Care Follow-up. Journal of Emergency Medicine. May 2011; Retrieved online on April 9, 2011 from website: http://www.sciencedirect.com.proxy.libraries.uc.edu/science/article/pii/s0736467911010286 Standards of Medical Care in 2010. Care. January 2010; 33:511-561
EmergencyKT: Disposition for Hyperglycemic/Diabetic Patients Discharged from the ED 1. Hyperglycemia identified and treated 2. All applicable lab work obtained: CBCD, EP1, Mag, Phos, VBG, HbA1c, Serum Ketones, UA/Preg 3. Underlying cause of blood sugar variation/infection identified and treated 1. Glucose ideally < 250 2. No Recent Hypoglycemia 3. Vital Signs Stable 4. Ability to tolerate PO 5. Anion Gap < 15 6. Competent to perform basic diabetic care (able to recognize hyperglycema and hypoglycemia) HbA1c % Control card. Type 2 - Cell Biology. Obtained online on April 14 from website: http://pt851.wikidot.com/ type-2-diabetes-cell-biology <5.9 6-7 7.1-8 8.1-9 9.1-11 >12 Increased Hypoglycemic Risk (consider DM clinic referral) yes Consider Diabetic Clinic Referral yes Consider Admission (for intensive glucose management) Referral to Adele Corbin (@ Hoxworth diabetes clinic) for urgent DM follow up. Call 584-0942 and leave up to date patient contact Information, brief patient history and current HbA1c result (if available at time of discharge) Follow up with PCP < 7 days If PCP, consider urgent medicine clinic referral Ensure that patient has all needed diabetic supplies including glucometers, and Rx refill for supplies if needed (free glucometers and generic Rx forms for common medications and DM supplies can be found in the radio room, see DM Committee member if ne are available). Brief diabetes education and discharge instructions specific for diabetes (found on CPQE). Follow up with PCP If PCP, consider urgent medicine clinic referral
Lifetime Benefits and Costs of Intensive Therapy as Practiced in the Control and Complications Trial. The Journal of the American Medical Association. 1996; 17:1409-1415 Ginde AA, Talley BE, Trent SA. Raja AS, Sullivan AF, Camargo CA. Referral of Discharged Emergency Department Patients to Primary and Specialty Care Follow-up. Journal of Emergency Medicine. May 2011; Retrieved online on April 9, 2011 from website: http://www.sciencedirect.com.proxy.libraries.uc.edu/science/article/pii/s0736467911010286 Standards of Medical Care in 2010. Care. January 2010; 33:511-561