Diabetes: An opportunity for community paramedicine
In the United States today, 8.3 percent of adults live with diabetes. Vascular complications make diabetes responsible for 14 percent of all health care expenditures. In fact, people with diabetes are twice as likely to die as their same-aged peers.
The most common complications of diabetes include myocardial infarction, stroke, end-stage renal disease, retinopathy, and foot ulcers. Additionally, people with diabetes are more prone to depression, absenteeism, and work productivity problems, all of which affect employment, quality of life and economic stability.
EMS calls related to blood sugar levels normally comprise 4 percent of all responses, depending on community demographics. Virtually every EMS provider has seen patients with poorly managed diabetes — and herein lies an opportunity for community paramedics. Interventions to improve glycemic control and manage complications of diabetes can reduce 911 responses, prevent hospitalizations, and significantly reduce health care expenditures.
The American Diabetes Association (ADA) publishes guidelines for medical management of diabetes, updated annually.
For many years, diabetes was diagnosed using either fasting plasma (blood) glucose or an oral glucose tolerance test. This practice was abandoned in 2009 when an international panel of experts recommended use of the A1C test, also called the HbA1C, hemoglobin A1C or glycohemoglobin. When glucose levels in the bloodstream increase, some glucose molecules attach to hemoglobin. Measured as a percentage, a normal A1C is less than 5.7 percent, and the threshold for diagnosing diabetes is 6.5 percent or greater.
The life of a hemoglobin unit is typically three months, so an A1C test reflects blood glucose levels for the prior three-month period; fasting is not required before drawing the blood. A1C is also used to monitor glycemic control in patients with diabetes, often choosing targets of 7 percent or less in non-pregnant adults, 6.5 percent or less in select (higher risk for complications) populations, and 8% or less in patients with frequent episodes of hypoglycemia.
Familiarity with A1C values is important for paramedics. Use of a glucometer is now an EMT-level skill. As such, EMS needs to step up as a partner in health care and make a habit of checking capillary blood glucose on every patient with diabetes. Knowing the targets for proper control, measuring blood glucose at the time of treatment, and discussing the results with patients will help to reinforce the importance of good glycemic control.
Community paramedic opportunities
Contemporary treatment of diabetes involves anti-diabetes medications (oral and/or injected), diet, and blood glucose measurement, all of which take significant involvement on the part of patients. The education and support required are substantial but have been recognized to significantly reduce complications and therefore, are reimbursed by both Medicare and most health insurance payers.
One potential role for community paramedics could be working in concert with diabetes educators to reinforce practices such as self-monitoring blood glucose (SMBG) using a glucometer, maintaining an awareness for potential hypoglycemia, and recognizing events that may lead to low blood sugar such as fasting, heavy exercise, and sleep. Paramedics should be familiar with treatment standards for diabetes and assure that patients have been prescribed and have access to glucagon and that their family members or friends are familiar with how to administer it.
Any hypoglycemic episode that requires intervention from others should prompt a referral to the patient’s health care provider for reevaluation. These patients should also have their diabetes care overseen by an endocrinologist.
Call the doctor
One of the first questions every EMS service should ask is whether each patient’s treating health care provider is aware of EMS responses involving diabetes-related concerns. Especially in cases where EMS treats a hypoglycemic episode without transporting the patient, a report or phone call should be made to the patient’s health care provider. Otherwise, it is fully possible that the health care provider is unaware of what is obviously poor glycemic control.
This is the mindset of the community paramedic movement: considering not only the need for a 911 response, but the factors that led up to that emergency and the resulting costs to the patient, the community, and the healthcare system.
It is abundantly obvious that many EMS responses are inappropriate. The changes in health care reimbursement and coverage will be focused not on paying for care as they have in the past, but on paying for health.
Consider that hypoglycemic events are common in people with type 1 diabetes. The average patient experiences countless incidents of asymptomatic hypoglycemia, two episodes of symptomatic hypoglycemia weekly, and at least one temporarily disabling hypoglycemic episode per year. Severe hypoglycemic events of the type in which EMS would become involved range from 62 to 170 episodes per 100 patient-years, equating to about the annual call volume of 3 to 4 percent of EMS runs in an average community.
The overall rate of severe episodes in persons with type 2 diabetes is lower, but still significant, comprising about 40 percent the incidence of persons with type 1 diabetes. Unfortunately, hypoglycemic episodes often lead to reduced awareness of hypoglycemia, leading to additional episodes. There are well-validated behavioral approaches that can be used to improve a patient’s ability to recognize hypoglycemia. Community paramedics can play a significant role in these approaches.
EMS and diabetes management
Imagine an EMS agency partnering with a certified diabetes educator (CDE, a health care professional with a recognized specialty certification in diabetes education) to routinely visit patients with diabetes in the community.
There are a wide range of preventative services recommended for people with diabetes: smoking cessation, blood pressure control, eye examinations, routine foot examinations and foot care, dental examinations, blood work including A1C and lipid monitoring, vaccinations, and ongoing education on diet and medications. Many of these are well within the ability of a paramedic.
Unlike most other health care professionals, EMS providers are ultimately comfortable working in the community, seeing patients in their homes, and creatively addressing challenges in the home environment.
Opportunities for just such collaborative efforts exist currently. The New York Mobile Integrated Healthcare Association (NYMIHCA) website describes community paramedicine using examples of programs currently up and running across the United States.
Assert your skills
Unfortunately, it’s highly unlikely that anyone is going to come knocking on your door with an offer. Each EMS agency needs to form alliances with their local hospitals, home health care organizations, and community physicians and medical practices to discuss needs and inform the medical community of the capabilities of EMS.
For years, the only interface that EMS has had with the medical community is at the emergency department, with an occasional appearance to extract someone from a community physician’s office. The skill set of EMS — especially our ability to navigate about the community and work comfortably in the home environment — is totally unknown to administrators, discharge planners, public health workers, and insurers.
Delivery of home-based care of all sorts is a hot topic in health care, and every spectrum of the health care delivery system is currently contemplating how they can best extend their reach into the community. Failure to initiate discussions and look for unique and more effective ways of serving EMS patients will assure that someone else will assume this role.
Make yourself useful
EMS calls of today are like the fire calls of 30 years ago: injury and illness prevention programs now being organized will sharply reduce the need for transports in the future. All of us need to think about preventative health care for the many 911 responses we make into our communities and then get involved in the process so we don’t find ourselves out of work once the need for transports starts to fade. The future is now.
Consider some of the most frequent 911 responses you make. Diabetes is certainly one of those; in fact, diabetes probably accounts for six to 10 times as many calls as cardiac arrest.
Those frequent responses all present opportunities for community paramedic ventures. Many of them require no additional training, just a shift in response and some collaboration with segments of the health care system we are not accustomed to working with.
1. Centers for Disease Control and Prevention. 2011 National Diabetes Fact Sheet www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf (Accessed December 12, 2013).
2. Mokdad AH, Ford ES, Bowman BA, et al. Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. JAMA 2003; 289:76.
3. American Diabetes Association. Standards of medical care in diabetes--2013. Diabetes Care 2013; 36 Suppl 1:S11. (Available at: http://care.diabetesjournals.org/content/36/Supplement_1/S11.full.pdf).
4. The International Expert Committee. International Expert Committee report on the role of the A1C assay in the diagnosis of diabetes. Diabetes Care. 2009;32(7):1327–1334.
5. Cryer PE. Hypoglycemia in Diabetes. Pathophysiology, Prevalence and Prevention, American Diabetes Association, Alexandria 2009.
6. Leese GP, Wang J, Broomhall J, et al. Frequency of severe hypoglycemia requiring emergency treatment in type 1 and type 2 diabetes: a population-based study of health service resource use. Diabetes Care 2003; 26:1176.
7. Cox DJ, Kovatchev B, Koev D, et al. Hypoglycemia anticipation, awareness and treatment training (HAATT) reduces occurrence of severe hypoglycemia among adults with type 1 diabetes mellitus. Int J Behav Med 2004; 11:212.Mike McEvoy, PhD, NRP, RN, CCRN is the EMS Coordinator for Saratoga County, New York and a paramedic supervisor with Clifton Park & Halfmoon Ambulance. He is a nurse clinician in cardiothoracic surgical intensive care at Albany Medical Center where he also Chairs the Resuscitation Committee and teaches critical care medicine. He is a lead author of the “Critical Care Transport” textbook and Informed® Emergency & Critical Care guides published by Jones & Bartlett Learning. Mike is a frequent contributor to EMS1.com and a popular speaker at EMS, Fire, and medical conferences worldwide. Contact Mike at email@example.com.
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