Variability in the Treatment of Prehospital Hypoglycemia: A Structured Review of EMS Protocols in the United States

Abstract: Background: In many industries, limiting variability in process has been associated with a reduction in errors. Hypoglycemia is a common prehospital diabetic emergency for which most EMS systems have a treatment protocol. Objective: To examine the treatment variability for prehospital hypoglycemia within EMS protocols in the U.S. Methods: EMS protocols were reviewed in a structured fashion from 2 sources: the website www.emsprotocols.org and through manual identification from the 50 largest populated cities in the U.S. Data was abstracted by trained investigators regarding the concentration of glucose recommended for the parenteral reversal of hypoglycemia, clinical treatment thresholds, dose recommendations, follow-up care, and non-transport policies. Descriptive statistics were used to summarize the findings. We also reviewed these EMS protocols for the protocol's effective date, the presence of a specific hypoglycemia patient non-transport policy, the use of dilutions of hypertonic dextrose for pediatric patients, glucagon use, and CBG or GCS for patient follow-up. Results: Protocols were retrieved from 185 EMS agencies of a variety of sizes across the U.S. Seventy percent specified only D50 for the treatment of hypoglycemia in adult patients, 8% only D10, and 22% either D10 or D50. Most protocols (85%), which used D50, specified concentration dilutions for pediatric patients. The most frequently specified initial dose of glucose was 25 g of glucose for adults (73–78%), 0.5 g/kg for pediatric (70%), and 0.5 g/kg for neonates (45%). The median blood glucose level threshold for treatment was 60 mg/dl for patients of all ages, but the mean treatment threshold levels for adults, pediatric patients and neonates were statistically different (p < 0.0001). Nearly all protocols (97%) allowed for the use of glucagon in the absence of vascular access. Patient follow up with a repeat CBG was recommended in 32%, both CBG and GCS in 31%, GCS only in 4%, and no follow-up was specified in 33% of the protocols. A specific policy permitting the non-transport of select patients whose hypoglycemia had been corrected was noted in slightly less than half (49%) of the protocols. Conclusions: In the U.S., EMS protocols for the treatment of hypoglycemia vary significantly. Further studies are warranted to determine the factors underlying this variability and effects on patient outcomes.