Johnson-Clague et al evaluated 161 patients in a retrospective cohort study in an academic emergency department.⁴ Diabetic adults with a glucose of greater than 200 mg/dL were treated with subcutaneous insulin. Their glucose was measured 24 hours after discharge. Whether the glucose was above or below 200 had no apparent impact on hospital length of stay.

However, not everyone agrees. A 2011 article from Munoz et al reported a reduced hospital length of stay in ED patients who received subcutaneous insulin every two hours until their glucose was below 200 mg/dL (3.8 days versus 5.3 days).⁵ However, the intervention group of only 44 patients who all received insulin was compared to a historical control group in which only 35 percent received insulin. In addition, despite the difference being statistically significant (P <0.05), this is not clinically significant because the primary reason for admission was more likely the driver for length of stay than the patient’s glucose level.

In a recent study by Driver et al, a retrospective cohort chart review of 422 patients was performed and included only patients who were discharged and had a glucose level of equal to or greater than 400 mg/dL at some point during their ED visit.⁶ The mean arrival and discharge glucose levels were 491 mg/dL and 334 mg/dL, respectively. Seven percent (36 patients) returned for hyperglycemia and were admitted within seven days. However, after adjusting for several variables, including arrival glucose and the amount of insulin received, the discharge glucose was not associated with return ED visits or hospitalization for any reason.

Although all of these studies have limitations, we are comparing them to the physiologic argument that reducing elevated glucose must be a good thing. It’s time to stop a practice that seemed to make reasonable sense but has no proven benefit.

References

1. Litzendorf ME, Satiani B. Superficial venous thrombosis: disease progression and evolving treatment approaches. Vasc Health Risk Manag. 2011;7:569-575.
2. Binder B, Lackner HK, Salmhofer W, et al. Association between superficial vein thrombosis and deep vein thrombosis of the lower extremities. Arch Dermatol. 2009;145(7):753-757.
3. Goyal N, Tsivgoulis G, Zand R, et al. Systemic thrombolysis in acute ischemic stroke patients with unruptured intracranial aneurysms. Neurology. 2015;85(17):1452-1458.
4. Johnson-Clague M, Dileo J, Katz MD, et al. Effect of full correction versus partial correction of elevated blood glucose in the emergency department on hospital length of stay. Am J Ther. 2016;23(3):e805-e809.
5. Munoz C, Villanueva G, Fogg L, et al. Impact of a subcutaneous insulin protocol in the emergency department: Rush Emergency Department Hyperglycemia Intervention (REDHI). J Emerg Med. 2011;40(5):493-498.
6. Driver BE, Olives TD, Bischof JE, et al. Discharge glucose is not associated with short-term adverse outcomes in emergency department patients with moderate to severe hyperglycemia. Ann Emerg Med. 2016;68(6):697-705.