SHORT REPORT

Pilot study of random finger prick glucose testing as a screening tool for type 2 diabetes mellitus in the emergency department

N Hewat¹, D McD Taylor¹, E MacDonald²

¹ Emergency Department, Austin Hospital, Victoria, Australia
² Worthing Hospital, Sussex, UK

Correspondence to:
^{Correspondence to} A/Prof D McD Taylor, Emergency Department, Austin Hospital, Studley Road, Heidelberg, Victoria 3084, Australia; david.taylor{at}austin.org.au

Accepted 9 February 2009

Background: A study was undertaken to determine the prevalence of undiagnosed hyperglycaemia among patients in the emergency department (ED) and to evaluate the usefulness of random fingerprick plasma glucose (RFPG) screening in the ED with GP follow-up.

Methods: A cross-sectional pilot study of 101 non-diabetic patients in the ED aged 45 years was performed.

Results: 31 (30.7%) had never had diabetic screening. 67 (66.3%) had plasma glucose levels 5.5 mmol/l and were advised to consult their GP; 38 (56.7%) did so and 23 (60.5%) of these had follow-up testing. Nine patients (8.9%) were ultimately diagnosed with impaired glucose metabolism.

Conclusion: There is considerable potential for diabetic screening in the ED setting.

It is estimated that 7.2% of Australians aged >25 years have type 2 diabetes mellitus and that 50% are undiagnosed.^{1 2 3 4} We aimed to determine the prevalence of undiagnosed hyperglycaemia among patients in the emergency department (ED) and to evaluate the usefulness of random fingerprick plasma glucose (RFPG) screening in the ED with GP follow-up.

A prospective cross-sectional pilot study was performed between June 2006 and March 2007 in a tertiary referral ED (annual census 55 000). Convenience samples of consecutive patients presenting during 13 separate 4-hour enrolment periods on all 7 days of the week were enrolled. Enrolment periods were dictated by the availability of the principal investigator, were scattered throughout the study period and comprised approximately equal numbers of 08.00–12.00 h, 12.00–16.00 h and 16.00–20.00 h blocks. Patients were excluded if they were aged <45 years, refused to participate, were diabetic or unable to consent due to illness or communication difficulty.

Data were collected using a researcher-administered questionnaire prior to RFPG testing. The primary end points were the proportions of patients who had hyperglycaemia (RFPG 5.5 mmol/l, the Diabetes Australia screening cut-off level), who followed up after an abnormal screening result and who were ultimately found to have abnormal glucose tolerance.

The RFPG was measured with a single MediSense Optium machine (Abbott Laboratories, Doncaster, Australia). Patients with RFPG 5.5 mmol/l were advised to consult their GP within 1 month of discharge and were followed up by telephone at 2 months.

Of 394 consecutive patients who presented during the 13 enrolment periods, 293 were excluded (178 aged <45 years, 46 diabetic, 61 unable to consent, 8 refused). Of the 101 patients enrolled, 31 (30.7%, 95% confidence interval (CI) 22.1% to 40.8%) had never been screened for diabetes. Sixty-seven patients (66.3%, 95% CI 56.2% to 75.3%) had an RFPG 5.5 mmol/l (range 5.5–12.7 mmol/l). Thirty-eight (56.7%) of these followed up with their GP and 23 (60.5%) had follow-up tests. Nine enrolled patients (8.9%, 95% CI 4.4% to 16.7%) were ultimately diagnosed with impaired glucose metabolism.

Patients failed to follow up for a variety of reasons including no memory of the ED visit or GP referral letter (n = 12), too busy (n = 9), thinking the hospital would take care of them (n = 7), having died (n = 6) or being too ill (n = 5).

Patients with RFPG 5.5 mmol/l tended to be female and to have a family history of diabetes, a lower level of education, a higher body mass index and symptoms of polydipsia (table 1).

View this table: in this window | in a new window   Table 1 Patient variables as a function of RFPG level

 

While approximately 9% of our patients were diagnosed with abnormal glucose tolerance, the true prevalence is unknown as almost half did not follow up. However, the results are consistent with other ED studies and indicate that considerable proportions of patients in the ED with this condition are undiagnosed. George et al⁵ identified 4.9% of patients with undiagnosed abnormal glucose tolerance. Charfen et al⁶ found that 130 (67.0%) of 194 high-risk or hyperglycaemic patients had potentially clinically important abnormalities of glucose homeostasis on retesting.

Given these findings, there is considerable potential for diabetic screening in the ED setting. Ultimately, however, the success of ED screening will be dependent upon follow-up testing. Effort is required to maximise follow-up rates including mailing GPs directly, ED diabetes education and alternatives for follow-up testing. The failure of some GPs not to retest was surprising but consistent with the low rates of previous screening. The findings suggest a lack of GP proactivity rather than infrequent GP visits. The enthusiasm expressed by our patients for opportunistic screening in the ED is encouraging. However, cost-effectiveness studies to evaluate the resource implications and ultimate worth of ED screening will be required.

^Funding None.

^{Competing interests} None.

^{Ethics approval} The study was authorised by the institution’s ethics committee.

^{Provenance and peer review} Not commissioned; externally peer reviewed.

1. Australian Institute of Health and Welfare (AIHW). Diabetes: Australian facts 2002 . AIHW Cat. No. CVD 20 (Diabetes Series No 3). Canberra: AIHW, 2002.
   
2. Guest C, O’Dea K, Hopper J, et al.. The prevalence of glucose intolerance in Aborigines and Europids of south-eastern Australia. Diabetes Res Clin Pract 1992;15:227–35.[CrossRef][Medline]
   
3. McCarty DJ, Zimmet P, Dalton A, et al.. The rise and rise of diabetes in Australia, 1996: a review of statistics, trends and costs . Canberra: International Diabetes Institute and Diabetes Australia, 1996.
   
4. Dunstan D, Zimmet P, Welborn T, et al.. Diabesity and associated disorders in Australia 2000. The accelerating epidemic . Australian Diabetes, Obesity and Lifestyle Study (AusDiab). Melbourne: International Diabetes Institute, 2001.
   
5. George PM, Valabhji J, Dawood M, et al.. Screening for type 2 diabetes in the accident and emergency department. Diabet Med 2005;22:1766–9.[CrossRef][Medline]
   
6. Charfen MA, Ipp E, Qazi MF, et al.. The yield of screening for diabetes in high-risk emergency department patients. Acad Emerg Med 2006;13(Suppl 1):121–2.[CrossRef][Medline]
   

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