Provider Response to Critical Action Values for Hypoglycemia in the Ambulatory Setting: a Retrospective Cohort Study
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Division of General Internal Medicine, Johns Hopkins University School of Medicine Baltimore, MD, USA; 2Division of Endocrinology, Diabetes, & Metabolism, Johns Hopkins University School of Medicine Baltimore, MD, USA.
BACKGROUND: The blood glucose level triggering a critical action value (CAV) for hypoglycemia is not standardized, and associated outcomes are unknown. OBJECTIVE: To evaluate the clinical consequences of, and provider responses to, CAVs for hypoglycemia. DESIGN: Retrospective cohort study at Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center between April 1, 2013, and January 31, 2017. PARTICIPANTS: Patients with an ambulatory serum glucose < 50 mg/dL. Point-of-care capillary glucose and whole blood glucose samples were excluded. MAIN MEASURES: Electronic medical record (EMR) review for providers’ documented response to CAV, associated patient symptoms, and serious adverse events. KEY RESULTS: We analyzed 209 CAVs for hypoglycemia from 154 patients. The median age (IQR) was 59 years (46, 69), 89 (57.8%) were male, and 96 (62.3%) were black. Provider-to-patient contact occurred in 128 of 209 (61.2%) episodes, among which no documented etiology was observed for 81 of 128 (63.3%), no recommendations were provided in 32 of 128 (25.0%), and no patientreported hypoglycemic symptoms were documented in 103 of 128 (80.5%). Serious adverse events were documented in 4 of 128 episodes (3.1%), two required glucagon administration, and three required an ED visit. Providerto-patient contact was associated with the patient having malignant neoplasm (adjusted OR 3.63, p = 0.045) or a hypoglycemic disorder (adjusted OR 7.70, p = 0.018) and inversely associated with a longer time from specimen collection to EMR result (adjusted OR 0.90 per hour, p = 0.016). CONCLUSIONS: There is inconsistent provider-to-patient contact following CAVs for hypoglycemia, and the etiology and symptoms of hypoglycemia were infrequently documented. There were few serious documented adverse events associated with hypoglycemia, although undocumented events may have occurred, and the incidence of serious adverse events in non-contacted patients remains unknown. These findings demonstrate a need to standardize provider response to CAVs for hypoglycemia. Decreasing the lag time between sample collection and
Received May 9, 2020 Accepted September 7, 2020
laboratory result reporting may increase provider-topatient contact. KEY WORDS: Hypoglycemia; Critical action value; Ambulatory; Glucose. J Gen Intern Med DOI: 10.1007/s11606-020-06225-y © Society of General Internal Medicine 2020
INTRODUCTION
A critical action value (CAV) is a test result that is potentially life threatening if not promptly intervened upon.1 Hypoglycemia is one such example as, if left untreated, it can lead to altered mentation, coma, or death.2 The International Hypoglycaemia Study Group considers a glucose concentration < 54 mg/dl (3.0 mmol/L) to be clinically important, serious hypoglycemia.3 Translating these concepts into a CAV for hypoglycemia that can b
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