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Three Part Question

For [diabetic patients who call 999 for hypoglycaemia symptoms] does [a pre-hospital referral to specialist diabetes services] improve [long term management of the patient’s diabetes resulting in fewer ambulance calls or ED attendance]

Clinical Scenario

A 64 year old male with Type 1 diabetes is experiencing symptoms of hypoglycaemia and his wife calls 999. An ambulance crew attend the patient who is drowsy and non-cooperative with blood sugar 1.8mmol/l. Following treatment with intramuscular glucagon and oral carbohydrate, he fully recovers and you follow guidelines that suggest the patient can be left at home with a referral to their GP, but you worry that without diabetes specialist input the patient will not have timely follow up resulting subsequent hypoglycaemic events with ambulance call out.

Search Strategy

The Cochrane Library: MeSH descriptor: [Emergency Medical Services] AND hypoglyc*
Embase 1996-2016 using the Pubmed interface:
(((diabetes OR diabetes mellitus OR diabetic)) AND (ambulance OR paramedic OR pre-hospital OR prehospital OR EMS OR emergency medical services)) AND hypoglyc*

269 papers found of which 266 irrelevant or insufficient quality for inclusion

Search Outcome

269 papers found of which 266 irrelevant or insufficient quality for inclusion

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Duncan E. A., and Fitzpatrick, D., 2016 UK	Adults attended by ambulance service due to hypoglycaemic emergency by paramedics from 7 ambulance stations. Patients provided with a prompt card to contact their healthcare provided and a follow-up phone call January 2012 to August 2012 (8 months). 107 patients not transported to ED included from 280 calls	Prospective cohort	Patients responded positively to the prompt card.	Proactive telephone follow-up was considered useful to patients and ambulance clinicians	Using proxy measures in the linked data so may underestimate the attendance at follow-up health care post-event. Small number of patients included. Only 36% patients received both prompt card and telephone follow-up call.
			69% patients received a follow-up telephone call and most reported that the most appropriate timeframe for the follow-up call would be 1-3 days post event.
			Linkage to SCI-Diabetes database for emergency calls was achieved for 205/280 calls and showed no difference between the conveyed and non-conveyed patients in attending at follow-up health care.
			Intervention was generally perceived to be very acceptable and feasible in practice
Walker A. et al , 2006 United Kingdom	Evaluation of Ambulance crew referral for post-hypoglycaemic patients to Diabetes Specialist Nurse service	Prospective cohort study	53% referred patients had altered medication.	All 38 patients (100%) spoke to the specialist nurses about the hypoglycaemic episode and 30 (79%) attended for review with the specialist nurses.	Small number of patients included.
			37% needed a second review appointment, and 16% required other intervention – all received advice and of the 26 patients who returned a questionnaire 88% agreed that they had improved their understanding of hypoglycaemic episode

Comment(s)

JRCALC guidelines indicate that ambulance services must arrange locally for a message to be forwarded to the local primary care or diabetes nurse team for patients who have been left at home after a moderate or mild hypoglycaemia event. However there is little evidence about how these referral pathways should be constructed, how they should be managed, their acceptability to patients and clinicians, and their effectiveness in reducing complications and supporting the long term management of patient’s diabetes. Some studies have demonstrated that some patients may lack a willingness to seek follow-up care. However, the limited evidence available found that patients and clinicians responded well to the two pathways that were tested whereby patients were not conveyed to hospital. No studies looked at referral pathways in patients who were conveyed to ED.

Clinical Bottom Line

Specialist diabetes referrals by ambulance crews after hypoglycaemia emergency calls may be beneficial for patients but there is insufficient evidence of their implementation to determine their impact.

References

1. Fitzpatrick D, Duncan EA Improving post-hypoglycaemic patient safety in the prehospital environment: a systematic review. Emerg Med J. 2009; 26(7):472-8
2. Duncan EA, Fitzpatrick D. Improving self-referral for diabetes care following hypoglycaemic emergencies: a feasibility study with linked patient data analysis. BMC Emerg Med 2016; 16:13
3. Walker A, James C, Bannister M, et al. Evaluation of a diabetes referral pathway for the management of hypoglycaemia following emergency contact with the ambulance service to a diabetes specialist nurse team Emerg Med J 2006; 23(6):449-51