Evaluation of a Diabetic Ketoacidosis Order Set in Adults With Type 1 and Type 2 Diabetes at a Tertiary Academic Medical Centre: A Retrospective Chart Audit

Clark, Alexa; Kraut, Eyal; Yen, Hope; Moore, Sarah; Hopman, Wilma M.; Houlden, Robyn L.

doi:10.1016/j.jcjd.2018.11.004

Cited by 4 publications

(4 citation statements)

References 19 publications

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“…The median length of stay (LOS) in our study varied from 4 to 9 days, depending upon the type of SGLT2i. Variable LOS is reported before, ranging from 3.53 to 6 days 13,17 . The median time to close the anion gap was 2-3 days, based on the type of SGLT2i used, which is almost double compared to the previous 13,17 .…”

Section: Discussionmentioning

confidence: 99%

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SGLT-2 inhibitors associated euglycemic and hyperglycemic DKA in a multicentric cohort

Ata

Yousaf

Khan

et al. 2021

Sci Rep

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Euglycemic diabetic ketoacidosis (EuDKA) secondary to Sodium-glucose co-transporter-2 inhibitors (SGLT2i) in type 2 diabetes mellitus (T2D) is a rare but increasingly reported phenomenon. Not much is known about the burden of EuDKA in patients on SGLT2i or the associated factors. This retrospective cohort study tries to delineate the differences in factors associated with the development of EuDKA as compared to hyperglycemic DKA. We conducted a multicentre, retrospective study across three tertiary care centers under Weill Cornell affiliated-Hamad Medical Corporation, Qatar. The cohort comprised of T2D patients on SGLT2i who developed DKA between January 2015 to December 2020. The differences between the subjects who developed EuDKA or hyperglycaemic DKA (hDKA) were analyzed. A total of 9940 T2D patients were on SGLT2i during 2015–2020, out of which 43 developed DKA (0.43%). 25 developed EuKDA, whereas 18 had hDKA. The point prevalence of EuDKA in our cohort was 58.1%. EuDKA was most common in patients using canagliflozin, followed by empagliflozin and Dapagliflozin (100%, 77%, and 48.3%, respectively). Overall, infection (32.6%) was the most common trigger for DKA, followed by insulin non-compliance (13.7%). Infection was the only risk factor with a significant point estimate between the two groups, being more common in hDKA patients (p-value 0.006, RR 2.53, 95% CI 1.07–5.98). Canagliflozin had the strongest association with the development of EuDKA and was associated with the highest medical intensive care unit (MICU) admission rates (66.6%). In T2D patients on SGLT2i, infection is probably associated with an increased risk of developing EuDKA. The differential role of individual SGLT2i analogs is less clear and will need exploration by more extensive prospective studies.

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Section: Discussionmentioning

confidence: 99%

“…Variable LOS is reported before, ranging from 3.53 to 6 days 13,17 . The median time to close the anion gap was 2-3 days, based on the type of SGLT2i used, which is almost double compared to the previous 13,17 .…”

Section: Discussionmentioning

confidence: 99%

SGLT-2 inhibitors associated euglycemic and hyperglycemic DKA in a multicentric cohort

Ata

Yousaf

Khan

et al. 2021

Sci Rep

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“…Given the multiple complexities of managing inpatients with diabetes, there are data showing that when protocols are followed, outcomes are improved. 48,49 In the UK, an inquiry into excess deaths at one hospital suggested that one of the causes was an excess in variation in care and therefore any attempt to reduce variations in care across institutions and within institutions is to be welcomed. 50 It is perhaps for this reason that within the UK the JBDS-IP guidelines have been rapidly adopted because, even though they are consensus based, they are recognised as being useful, practical and of good quality.…”

Section: Protocol Driven Management Of Dysglycaemiamentioning

confidence: 99%

Safe care for people with diabetes in hospital

2020

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Diabetes is the most prevalent long-term condition, occurring in approximately 6.5% of the UK population. However, an average of 18% of all acute hospital beds are occupied by someone with diabetes. Having diabetes in hospital is associated with increased harm-however that may be defined. Over the last few years the groups such as the Joint British Diabetes Societies for Inpatient Care have produced guidelines to help medical and nursing staff manage inpatients with diabetes. These guidelines have been rapidly adopted across the UK. The National Diabetes Inpatient Audit has shown that over the last few years the care for people with diabetes has slowly improved, but there remain challenges in terms of providing appropriate staffing and education. Patient safety is paramount, and thus there remains a lot to do to ensure this vulnerable group of people are not at increased risk of harm.

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“…The paper by Clark et al (11) evaluates the impact of the implementation of an order set in 2013 at a tertiary care centre in Kingston, Ontario. Uptake of the order set was good at 84% of DKA admissions.…”

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confidence: 99%

The Use of Clinical Pathways and Order Sets in the Management of Diabetic Ketoacidosis

Lawrence

2019

Canadian Journal of Diabetes

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Diabetic ketoacidosis (DKA) is a common complication of both type 1 and type 2 diabetes in children and adults that is associated with significant morbidity and mortality. Clinical practice guidelines (CPGs) for DKA (1,2) have been used by many teaching hospitals to develop local DKA management guidelines. Despite widespread availability of CPGs, adherence rates remain low (3)(4)(5). Many patients present to community hospitals where protocols may not be readily available and the variability in management can be wide (6). The use of standardized clinical care pathways with established order sets have been shown to increase adherence to CPGs and decrease hospital costs and length of stay (6-9).In this issue are 3 papers addressing DKA management, including adherence to CPGs and the implementation of DKA order sets in pediatric and adult tertiary care settings in Canada. The first is a retrospective cohort study by Galm et al of patients admitted to 3 teaching hospitals (2 tertiary care and 1 community) in Edmonton, Alberta (10). Among the community feeder hospitals, only 1 of 14 had a standardized DKA protocol. Although the management of DKA was overall quite good, 4 notable areas for potential improvement were identified. These included 1) insufficient potassium replacement leading to hypokalemia in 41.7%, 2) giving a bolus of insulin to nearly 1 in 4 patients despite recommendations against this in the latest Diabetes Canada guidelines, 3) inappropriate use of bicarbonate, usually as a bolus (rather than slow infusion) or with only moderate DKA and 4) discontinuation of intravenous insulin before converting to subcutaneous insulin in 1 in 4 cases.The paper by Clark et al (11) evaluates the impact of the implementation of an order set in 2013 at a tertiary care centre in Kingston, Ontario. Uptake of the order set was good at 84% of DKA admissions. There was no significant difference between the groups for the outcomes measured including occurrences of hypokalemia, hypoglycemia and time to normalization of anion gap. It would be interesting to know the adherence rates to CPGs pre-and postimplementation of the order set.Flood et al (12) report on the uptake of a pediatric DKA order set and the impact of standard-of-care DKA management in a tertiary care centre in Saskatoon, Saskatchewan. They describe the process of the development and implementation of the order set, including stakeholder engagement, which is key to change management. Similar to Kingston, they observed 83% uptake of the order set. Significant improvements in adherence to standard of care management were observed in intravenous (IV) fluid rates, earlier and more appropriate addition of potassium to IV fluids and earlier addition of IV dextrose.While protocols exist in many larger teaching centres, the challenge is identifying a mechanism for order sets to be available in smaller centres. While the volume of patients with any one condition may be low in these centres, at a national level, we know that the majority of emergency department (ED) visits...

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Evaluation of a Diabetic Ketoacidosis Order Set in Adults With Type 1 and Type 2 Diabetes at a Tertiary Academic Medical Centre: A Retrospective Chart Audit

Cited by 4 publications

References 19 publications

SGLT-2 inhibitors associated euglycemic and hyperglycemic DKA in a multicentric cohort

SGLT-2 inhibitors associated euglycemic and hyperglycemic DKA in a multicentric cohort

Safe care for people with diabetes in hospital

The Use of Clinical Pathways and Order Sets in the Management of Diabetic Ketoacidosis

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