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National Estimates of Insulin-related Hypoglycemia and Errors Leading to Emergency Department Visits and Hospitalizations
The Journal of Emergency Medicine Comments: Poison center assistance was associated with lower total charges only among the most expensive to treat. However, this outlier group is very important when discussing medical costs. This study suggests that to maximize the value of PC assistance, a formalized triage scheme could be developed to help identify which patients would most benefit from the inclusion of toxicologists in their treatment process. , HYPOGLYCEMIA IS ASSOCIATED WITH INCREASED POSTBURN MORBIDITY AND MORTALITY IN PEDIATRIC PATIENTS. Jeschke MG, Pinto R, Herndon DN, Finnerty CC, Kraft R. Crit Care Med 2014;42:1221–31. The objective of this study was to determine the prevalence of hypoglycemia after severe burn injury (> 30% of total body surface area) and whether hypoglycemia is associated with increased postburn morbidity and mortality in pediatric patients. Seven hundred sixty patients were stratified according to the number of hypoglycemic episodes they experienced while in the intensive care unit. Clinical outcomes and metabolic inflammatory markers during the first 60 days post admission were analyzed. Patients with one or more hypoglycemic events (< 60 mg/dL glucose) were matched with patients not experiencing any hypoglycemic events using propensity score matching. Clinical outcomes and biomarker expression were compared between groups. Eighty-four patients had one episode of hypoglycemia and 108 patients had two or more episodes of hypoglycemia. The remaining 568 patients had no episodes of hypoglycemia. Hypoglycemic episodes correlated with injury severity and inhalation injury. When adjusted for injury severity, patients with one or more hypoglycemic episodes had longer hospitalizations, more frequent OR (Operating Room) visits, higher mortality rates, higher prevalence of multi-organ failure, and more infectious and septic episodes compared to patients with no hypoglycemic episodes (p < 0.05). [Jessica Slim, MD Denver Health Medical Center, Denver, CO] Comments: This study demonstrates that one or more episodes of hypoglycemia are associated with a significant increase in adverse clinical outcomes and death in pediatric burn patients. Prior studies have shown that in burn patients, glycemic control does provide improvements in wound healing time, decreases infection and sepsis, and increases survival. Thus, there is an important role for insulin administration in postburn patients, and strategies to lessen the chance of iatrogenic hypoglycemia are critical to patient outcomes. , BLOOD CULTURE USE IN THE EMERGENCY DEPARTMENT IN PATIENTS HOSPITALIZED FOR COMMUNITY-ACQUIRED PNEUMONIA. Makam AN, Auerback AD, Steinman MA. JAMA Intern Med 2014;174:803–6. The recommendation to obtain blood cultures for patients hospitalized with community-acquired pneumonia (CAP) was
255 revised by governing bodies in 2005 and 2007, ultimately to recommend obtaining blood cultures only for patients with severe CAP. This article sought to understand trends in obtaining blood cultures for CAP admissions from 2002 through 2010 in United States emergency departments. This retrospective study from the National Hospital Ambulatory Medical Care Surveys database found that in patients over 18 years of age hospitalized with CAP, there was an increase from a 29.4% culture rate in 2002 to a 51.1% culture rate in 2010 (p = 0.03). This amounted to a 73.4% relative increase in that time period, despite recommendations against routine blood cultures in CAP in 2005 and 2007. They also found through multivariable analysis that disease severity did not predict if patients had cultures, and intensive care unit admission was associated with lower odds of obtaining cultures. Privately owned hospitals, as well as hospitals in the northeast United States, were more likely to obtain blood cultures. The authors conclude that quality measures such as blood cultures being drawn prior to antibiotics being given (if blood cultures are indicated) is likely causing providers to order the blood cultures reflexively despite being unnecessary and perhaps harmful. [Cory Siebe, MD Denver Health Medical Center, Denver, CO] Comment: Despite governing body recommendations against routine blood cultures in stable CAP admission, blood cultures continue to be obtained in the emergency department at an increasing rate. , NATIONAL ESTIMATES OF INSULIN-RELATED HYPOGLYCEMIA AND ERRORS LEADING TO EMERGENCY DEPARTMENT VISITS AND HOSPITALIZATIONS. Geller AI, Shehab N, Lovegrove MC, et al. JAMA Intern Med 2014;174:678–86. Insulin is a high-risk medication used increasingly to treat type 2 diabetes mellitus (DM), an ever-increasing disease in the United States. This paper used a national database to further describe the epidemiology of insulin-related hypoglycemia and errors (IHEs) in patients presenting to emergency departments (EDs). The authors found that between 2007 and 2011, 9.2% of ED visits involved adverse drug events secondary to insulin use. In more than half of cases, blood glucose levels were 50 mg/dL or less and involved serious neurologic symptoms in about two-thirds. Patients 80 years and older had the highest rate of ED visits (34.9 per 1000 insulin-treated patients). This cohort was more than twice as likely to seek ED evaluation for IHE than those 65 to 79 years of age and was five times as likely to be hospitalized for IHEs as the 45 to 64 years group. More than one type of insulin product was documented in the record for 22.9% of ED visits, and long-acting insulin was documented in 32% of ED visits. Rapid-acting insulin products were involved 26.4% of the time. Precipitating factors for IHEs were documented in 20.8% of visits, and half of those involved mealrelated misadventures like not eating after taking insulin or not adjusting insulin correctly. In 22.1% of cases, the precipitant was taking the wrong insulin product, and 12.2% of cases
256 involved taking the wrong dose of insulin. Of these patients, 52.3% admitted to taking a rapid-acting product when meaning to take a long-acting insulin product. The authors conclude that tight glycemic control must be weighed against the high likelihood of IHEs among vulnerable older populations and should be a focus of new prevention strategies to prevent morbidity from this high-risk medication. [Cory Siebe, MD Denver Health Medical Center, Denver, CO] Comment: Insulin is a medication that often leads to morbidity and ED visits and admission. Balancing glycemic control and the risk of errors will be increasingly important as more of the population is diagnosed with type 2 DM. The epidemiology of insulin errors will direct future efforts for prevention and education. , HIGH VERSUS LOW BLOODPRESSURE TARGET IN PATIENTS WITH SEPTIC SHOCK. Asfar P, Meziani F, Hamel JF, et al. N Engl J Med 1014;370:1583–93. The Surviving Sepsis Campaign recommends resuscitating to a mean arterial pressure (MAP) of 65 mm Hg for patients in septic shock, but it is unknown whether higher MAPs might be beneficial to maintain vital organ function and prevent mortality. This study compared MAPs of 80 to 85 with current recommendations of 65 to 70 mm Hg in patients with septic shock undergoing resuscitation, with the primary outcome of mortality at 28 days. It was a randomized, stratified (if they had a history of chronic hypertension), open-label trial. The authors enrolled 776 patients, following to 90 days. They found no significant difference between groups with respect to rate of death (36.6%) in the high MAP group and 34.0% in the low MAP group (confidence interval 0.84–1.38). They also found no difference in mortality at 90 days (43.7% vs. 42.3%). There was also no difference in the secondary outcomes of need for mechanical ventilation, or length of stay in the intensive care unit and hospital. In patients with chronic arterial hypertension, there was less need for renalreplacement therapy in the higher target MAP group than the lower MAP group, but this was also not shown to affect mortality. They did find that there were more episodes of atrial fibrillation in the high-target MAP group, but again, did not affect mortality. The authors note that the observed MAP in the low target group did overshoot the goal of 65 to 70 mm Hg and were mostly between 70 and 75 mm Hg. The difference between the two groups was maintained, however, because the values for the high-target MAP group were between 85 and 90 mm Hg when the goal was 80 to 85 mm Hg. It is unknown if this affected the results, but the results show good correlation with previously cited sepsis mortality data. The authors conclude that 28-day and 90-day mortality did not differ between a high MAP goal and a traditional (lower) goal. [Cory Siebe, MD Denver Health Medical Center, Denver, CO] Comment: The high mortality of sepsis continues to be an area of high-yield research and investigation that must continue.
Abstracts This trial shows us that preliminarily, higher MAP goals, although making intuitive sense, do not equate with decreased mortality. , HIGH-RISK USE BY PATIENTS PRESCRIBED OPIOIDS FOR PAIN AND ITS ROLE IN OVERDOSE DEATHS. Baumblatt J, Wiedeman C, Dunn J, et al. JAMA Intern Med 2014;174:796–801. Tragically, between 1990 and 2010, drug overdose deaths increased threefold in the state of Tennessee; prescription opioid-related deaths substantially contributed to this drastic rise. To further examine opioid-prescribing patterns that directly contribute to these escalating numbers, a case-control study was designed to correlate opioid prescription data from the Tennessee Controlled Substances Monitoring Program (TNCSMP) from January 2007 through December 2011 to better identify risk factors associated with opioid overdose-related death. Between 2007 and 2011, the TNCSMP database noted a 32% increase in the amount of opioid prescriptions filled. Nearly one-third of the Tennessee population filled an opioid prescription each year. During 2009 and 2010, 923 opioid-related overdose deaths occurred in Tennessee. Increased risk of opioid overdose-related death was associated with having four or more prescribers of medications (adjusted odds ratio [aOR] 6.5, 95% confidence interval [Cl] 5.1–8.5), four or more pharmacies (aOR 6.0, 95% Cl 4.4–8.3), and more than 100 morphine milligram equivalents (MMEs) (aOR 11.2, 95% Cl 8.3–15.1). Persons with one or more risk factors accounted for 55% of all opioid overdose-related deaths. In turn, this study shows that high-risk use and prescribing practices are common and increasing rapidly in Tennessee. This article identified that patients with four or more prescribers or pharmacies and taking more than 100 MMEs per year are indicators of high-risk behavior and in turn are associated with increased risk of overdose. Prescription drug monitoring programs, such as the TNCSMP, may provide a way for better-directed risk identification and in turn, a venue for identifying at-risk patients. [Marc Quinlan, MD Denver Health Medical Center, Denver, CO] Comment: It is important to note that the TNCSMP does not include medications related to methadone treatment facilities, nor does it include out-of-state prescriptions, so one should suspect that the numbers mentioned above are likely higher. The next step will be to see if a study that includes a drug-monitoring system such as the TNCSMP can be used to not only identify high-risk patients, but also intervene in a beneficial manner. , A RANDOMIZED TRIAL OF PROTOCOL-BASED CARE FOR EARLY SEPTIC SHOCK. Yearly D, Kellum J, Huang D, et al. N Engl J Med 2014;370:1683–93. For more than a decade, early goal-directed therapy (EGDT) has been considered the mainstay approach for emergency department management of severe sepsis and septic shock. Recently, a multicenter randomized controlled trial was designed
255 revised by governing bodies in 2005 and 2007, ultimately to recommend obtaining blood cultures only for patients with severe CAP. This article sought to understand trends in obtaining blood cultures for CAP admissions from 2002 through 2010 in United States emergency departments. This retrospective study from the National Hospital Ambulatory Medical Care Surveys database found that in patients over 18 years of age hospitalized with CAP, there was an increase from a 29.4% culture rate in 2002 to a 51.1% culture rate in 2010 (p = 0.03). This amounted to a 73.4% relative increase in that time period, despite recommendations against routine blood cultures in CAP in 2005 and 2007. They also found through multivariable analysis that disease severity did not predict if patients had cultures, and intensive care unit admission was associated with lower odds of obtaining cultures. Privately owned hospitals, as well as hospitals in the northeast United States, were more likely to obtain blood cultures. The authors conclude that quality measures such as blood cultures being drawn prior to antibiotics being given (if blood cultures are indicated) is likely causing providers to order the blood cultures reflexively despite being unnecessary and perhaps harmful. [Cory Siebe, MD Denver Health Medical Center, Denver, CO] Comment: Despite governing body recommendations against routine blood cultures in stable CAP admission, blood cultures continue to be obtained in the emergency department at an increasing rate. , NATIONAL ESTIMATES OF INSULIN-RELATED HYPOGLYCEMIA AND ERRORS LEADING TO EMERGENCY DEPARTMENT VISITS AND HOSPITALIZATIONS. Geller AI, Shehab N, Lovegrove MC, et al. JAMA Intern Med 2014;174:678–86. Insulin is a high-risk medication used increasingly to treat type 2 diabetes mellitus (DM), an ever-increasing disease in the United States. This paper used a national database to further describe the epidemiology of insulin-related hypoglycemia and errors (IHEs) in patients presenting to emergency departments (EDs). The authors found that between 2007 and 2011, 9.2% of ED visits involved adverse drug events secondary to insulin use. In more than half of cases, blood glucose levels were 50 mg/dL or less and involved serious neurologic symptoms in about two-thirds. Patients 80 years and older had the highest rate of ED visits (34.9 per 1000 insulin-treated patients). This cohort was more than twice as likely to seek ED evaluation for IHE than those 65 to 79 years of age and was five times as likely to be hospitalized for IHEs as the 45 to 64 years group. More than one type of insulin product was documented in the record for 22.9% of ED visits, and long-acting insulin was documented in 32% of ED visits. Rapid-acting insulin products were involved 26.4% of the time. Precipitating factors for IHEs were documented in 20.8% of visits, and half of those involved mealrelated misadventures like not eating after taking insulin or not adjusting insulin correctly. In 22.1% of cases, the precipitant was taking the wrong insulin product, and 12.2% of cases
256 involved taking the wrong dose of insulin. Of these patients, 52.3% admitted to taking a rapid-acting product when meaning to take a long-acting insulin product. The authors conclude that tight glycemic control must be weighed against the high likelihood of IHEs among vulnerable older populations and should be a focus of new prevention strategies to prevent morbidity from this high-risk medication. [Cory Siebe, MD Denver Health Medical Center, Denver, CO] Comment: Insulin is a medication that often leads to morbidity and ED visits and admission. Balancing glycemic control and the risk of errors will be increasingly important as more of the population is diagnosed with type 2 DM. The epidemiology of insulin errors will direct future efforts for prevention and education. , HIGH VERSUS LOW BLOODPRESSURE TARGET IN PATIENTS WITH SEPTIC SHOCK. Asfar P, Meziani F, Hamel JF, et al. N Engl J Med 1014;370:1583–93. The Surviving Sepsis Campaign recommends resuscitating to a mean arterial pressure (MAP) of 65 mm Hg for patients in septic shock, but it is unknown whether higher MAPs might be beneficial to maintain vital organ function and prevent mortality. This study compared MAPs of 80 to 85 with current recommendations of 65 to 70 mm Hg in patients with septic shock undergoing resuscitation, with the primary outcome of mortality at 28 days. It was a randomized, stratified (if they had a history of chronic hypertension), open-label trial. The authors enrolled 776 patients, following to 90 days. They found no significant difference between groups with respect to rate of death (36.6%) in the high MAP group and 34.0% in the low MAP group (confidence interval 0.84–1.38). They also found no difference in mortality at 90 days (43.7% vs. 42.3%). There was also no difference in the secondary outcomes of need for mechanical ventilation, or length of stay in the intensive care unit and hospital. In patients with chronic arterial hypertension, there was less need for renalreplacement therapy in the higher target MAP group than the lower MAP group, but this was also not shown to affect mortality. They did find that there were more episodes of atrial fibrillation in the high-target MAP group, but again, did not affect mortality. The authors note that the observed MAP in the low target group did overshoot the goal of 65 to 70 mm Hg and were mostly between 70 and 75 mm Hg. The difference between the two groups was maintained, however, because the values for the high-target MAP group were between 85 and 90 mm Hg when the goal was 80 to 85 mm Hg. It is unknown if this affected the results, but the results show good correlation with previously cited sepsis mortality data. The authors conclude that 28-day and 90-day mortality did not differ between a high MAP goal and a traditional (lower) goal. [Cory Siebe, MD Denver Health Medical Center, Denver, CO] Comment: The high mortality of sepsis continues to be an area of high-yield research and investigation that must continue.
Abstracts This trial shows us that preliminarily, higher MAP goals, although making intuitive sense, do not equate with decreased mortality. , HIGH-RISK USE BY PATIENTS PRESCRIBED OPIOIDS FOR PAIN AND ITS ROLE IN OVERDOSE DEATHS. Baumblatt J, Wiedeman C, Dunn J, et al. JAMA Intern Med 2014;174:796–801. Tragically, between 1990 and 2010, drug overdose deaths increased threefold in the state of Tennessee; prescription opioid-related deaths substantially contributed to this drastic rise. To further examine opioid-prescribing patterns that directly contribute to these escalating numbers, a case-control study was designed to correlate opioid prescription data from the Tennessee Controlled Substances Monitoring Program (TNCSMP) from January 2007 through December 2011 to better identify risk factors associated with opioid overdose-related death. Between 2007 and 2011, the TNCSMP database noted a 32% increase in the amount of opioid prescriptions filled. Nearly one-third of the Tennessee population filled an opioid prescription each year. During 2009 and 2010, 923 opioid-related overdose deaths occurred in Tennessee. Increased risk of opioid overdose-related death was associated with having four or more prescribers of medications (adjusted odds ratio [aOR] 6.5, 95% confidence interval [Cl] 5.1–8.5), four or more pharmacies (aOR 6.0, 95% Cl 4.4–8.3), and more than 100 morphine milligram equivalents (MMEs) (aOR 11.2, 95% Cl 8.3–15.1). Persons with one or more risk factors accounted for 55% of all opioid overdose-related deaths. In turn, this study shows that high-risk use and prescribing practices are common and increasing rapidly in Tennessee. This article identified that patients with four or more prescribers or pharmacies and taking more than 100 MMEs per year are indicators of high-risk behavior and in turn are associated with increased risk of overdose. Prescription drug monitoring programs, such as the TNCSMP, may provide a way for better-directed risk identification and in turn, a venue for identifying at-risk patients. [Marc Quinlan, MD Denver Health Medical Center, Denver, CO] Comment: It is important to note that the TNCSMP does not include medications related to methadone treatment facilities, nor does it include out-of-state prescriptions, so one should suspect that the numbers mentioned above are likely higher. The next step will be to see if a study that includes a drug-monitoring system such as the TNCSMP can be used to not only identify high-risk patients, but also intervene in a beneficial manner. , A RANDOMIZED TRIAL OF PROTOCOL-BASED CARE FOR EARLY SEPTIC SHOCK. Yearly D, Kellum J, Huang D, et al. N Engl J Med 2014;370:1683–93. For more than a decade, early goal-directed therapy (EGDT) has been considered the mainstay approach for emergency department management of severe sepsis and septic shock. Recently, a multicenter randomized controlled trial was designed