Does a leaflet-based intervention, ‘Hypos can strike twice’, prevent recurrent hypoglycaemic attendances by ambulance services?

Talk Code: 
Vanessa Botan
Prof Graham R Law, Ms Despina Laparidou, Dr Elise Rowan, Dr Murray D. Smith, Dr Colin Ridyard, Prof. Niroshan A Siriwardena
Author institutions: 
University of Lincoln


Hypoglycaemia is a common complication in people with diabetes needing prompt recognition and treatment. It often results in ambulance attendance and is associated with morbidity, mortality, and increased health services costs. Patient education is important for maintaining glycaemic control and preventing recurrent hypoglycaemia. We investigated the effect of an intervention in which ambulance staff were trained to provide advice supported by a booklet - ‘Hypos can strike twice’- issued following a hypoglycaemic event to prevent future attendances.


We used a non-randomised stepped wedge-controlled design. The intervention was introduced at different times (steps) in different areas (clusters) of operation within East Midlands Ambulance Service NHS Trust (EMAS). During the first step (T0) no clusters were exposed to the intervention and during the last step (T3) all clusters were exposed. The main outcome was the number of unsuccessful ambulance attendances (i.e. attendance followed by a repeat attendance). Data were analysed using a general linear mixed model (GLMM) and an interrupted-time series analysis (ITSA). The achievement of a care-bundle (i.e. blood glucose recorded before and after treatment for hypoglycaemia) was also checked for.


The study included 4825 patients (mean age= 65.42 years, SD=19.42; 2166 females) experiencing hypoglycaemic events attended by EMAS. GLMM indicated a reduction in the number of unsuccessful attendances in the final step of the intervention when compared to the first (OR: 0.50, 95%CI: 0.33-0.76, p=0.001). ITSA indicated a significant decrease in repeat ambulance attendances for hypoglycaemia - relative to the pre-intervention trend (p=0.008). The hypoglycaemia care bundle was delivered in 66% of attendances during the intervention period, demonstrating a significant level of practice change (χ2=30.16, p<0.001).


The ‘Hypos can strike twice’ intervention had a positive effect on reducing numbers of repeat attendances for hypoglycaemia and in achieving the care bundle. The study supports the use of informative booklets by ambulance clinicians to prevent future attendances for recurrent hypoglycaemic events.

Submitted by: 
Vanessa Botan
Funding acknowledgement: 
This study has been funded by NIHR Applied Research Collaboration (ARC) East Midlands, UK