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This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.

A simple booklet, given along with advice from ambulance crews, can reduce the need for further emergency callouts for low blood sugar (hypoglycaemia or hypos). New research found that this cheap intervention reduced the number of repeat emergency callouts for hypoglycaemia. It helped people recognise early warning signs and manage their own condition.

Hypoglycaemia is a serious and common complication of diabetes. It can often be treated by eating glucose gel (fast-acting sugar). But without quick action, it can lead to confusion and loss of consciousness. People who have had an emergency callout for hypoglycaemia are very likely to call an ambulance for the same thing another time.

Researchers designed an information booklet on how to prevent these episodes, what the warning signs are, and how to manage them. Hypoglycaemia is largely preventable and the advice included, for example, eating regularly, only drinking alcohol with food, and eating starchier than usual foods before and after strenuous activity.

The study explored the impact of the booklet, combined with advice given by ambulance crews at the time of a callout for hypoglycaemia. During the course of the study, the number of repeat emergency callouts was reduced by half among people who received this cheap intervention. It empowered patients to manage their own hypoglycaemia and prompted ambulance staff to keep more complete records on hypoglycaemia callouts.

Further information about hypoglycaemia is available on the NHS website.

What’s the issue?

Hypoglycaemia occurs when people’s blood sugar levels drop too far. The early signs include feeling shaky, turning pale, tingling lips, feeling tired and sweating. If it is not treated, people can become weak, have blurred vision, lose consciousness and have a seizure. 

Anyone can have hypoglycaemia but it mainly affects people with diabetes who take insulin. Insulin helps the body use blood sugar; too much insulin can make blood sugar levels drop too far. Skipping a meal or drinking alcohol can also cause blood sugar to fall. 

Hypoglycaemia is usually treated by the person themselves, eating a starchy snack or glucose gel. However, when severe, people often need an ambulance visit and are sometimes admitted to hospital.

Emergency calls due to hypoglycaemia attended by the East Midlands Ambulance Service cost £235,407 per year. Managing severe episodes of hypoglycaemia (those resulting in hospital admission) costs the UK £296 million per year.

Helping people with diabetes understand and manage their condition could help them avoid long-term consequences, including cardiovascular disease and brain damage. It would also reduce ambulance call outs and NHS costs. The NHS aims to empower people to self-manage their condition. 

However, there has been conflicting evidence on whether booklets can reduce hypoglycaemia. This research assessed whether the Hypos can strike twice  intervention would reduce the need for further ambulance call outs. In this intervention, ambulance staff gave advice and a booklet when called out for people with hypoglycaemia.

This study also looked at how often ambulance staff delivered a care bundle of best practice for hypoglycaemia. A care bundle included ambulance staff recording blood glucose levels before and after treatment, and referring people to an appropriate community service.

What’s new?

The 26-month study was carried out in the region covered by the East Midlands Ambulance Service. It included data on 4825 people with an average age of 65 years (ranging from 16 to 104). Everyone in the study had received emergency ambulance care for a hypoglycaemic event (defined as a blood sugar level of 4mmol/L or lower).

The region was divided into three areas. Callouts in each area were monitored before the leaflets were introduced, and compared with callouts in the same area once the intervention was in place. The 'Hypos can strike twice' intervention was considered successful if the person did not call for an ambulance again for hypoglycaemia during the trial. 

Overall, the intervention reduced the number of people having a repeat callout for hypoglycaemia. 

The number of successful episodes (without repeat attendance) in the trial was:

    • 2,419 out of 3,048  (79%) before the intervention 
    • 1,522 out of 1,777 (86%) once the intervention had been introduced.

The ambulance crew sometimes forgot to provide advice, or to share the booklet. Even so, the number of repeat callouts was substantially reduced after this intervention was introduced. 

The figures were adjusted for the time of year, deprivation and people's age and gender. At the end of the study, when the intervention had been introduced into all areas, the researchers looked at what happened to the people who had received it. They found that this group had half the number of second emergency callouts compared to others at the start of the study.  

The best practice care bundle was completed more often once the intervention was rolled out. It may have prompted ambulance staff to record treatment; the first page of the booklet is a table of measurements.

The researchers looked at factors that affected emergency callouts. They found that men were more likely to have a callout than women. People living in deprived areas were also more likely than others to call an ambulance.  

Why is this important?

This study shows that a low-cost intervention reduced the number of repeat callouts for hypoglycaemia. The booklet was cheap to produce and simple. The team suggests that such an intervention could be applied to other services. 

This work shows the importance of helping people with diabetes to understand their condition and how to manage hypoglycaemia. It also shows the role of the ambulance crew in helping them to do this. 

The ultimate NHS goal is to help more people to live in their own homes for longer with major health problems. There is also a drive towards preventing unnecessary hospital admissions. Providing more information to people, at a key moment when they are especially receptive to it, could help.

What’s next?

As a result of the study, the team has shared the booklet with all ambulance services in the UK. They are free for services to print and use.

The team is now analysing interviews with both patients and staff involved in the study. They want to identify potential barriers to rolling out the intervention. Since staff are so busy, reminders about the booklet would be useful. Staff should be informed about its effectiveness.

More work could be done to refine the intervention based on the feedback received in this trial. The team would also like to explore translating the booklet into other languages to make it accessible for community groups.

You may be interested to read

This Alert is based on: Botan V, and others. The effects of a leaflet‐based intervention, ‘Hypos can strike twice’, on recurrent hypoglycaemic attendances by ambulance services: A non‐randomised stepped wedge study. Diabetic Medicine 2021;38:e14612 

The 'Hypos can strike twice' booklet for download.

Information about hypoglycaemia from Diabetes UK

Another study showing the impact of providing information to people with diabetes: Sankar V, and others. The impact of patient information leaflets to prevent hypoglycemia in out-patients with type 2 diabetes mellitus. Ars pharm 2019;60:5-14 


Funding: The study was funded by NIHR Applied Research Collaboration (ARC), East Midlands.

Conflicts of Interest: The study authors declare no conflicts of interest.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

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