Improving Emergency Department Management of Diabetic Ketoacidosis in Children

Abstract

BACKGROUND: Diagnostic delays in the pediatric emergency department (ED) can lead to unnecessary interventions and prolonged ED length of stay (LOS), especially in patients with diabetes mellitus evaluated for diabetic ketoacidosis (DKA). At our institution, baseline DKA determination time (arrival to diagnosis) was 86 minutes, and 61% of patients did not meet DKA criteria. Subsequently, intravenous (IV) placement occurred in 85% of patients without DKA. We aimed to use point-of-care (POC) testing to reduce DKA determination time from 86 to 30 minutes and to reduce IV placements in patients without DKA from 85% to 20% over 18 months. METHODS: Four key interventions (POC tests, order panels, provider guidelines, and nursing guidelines) were tested by using plan-do-study-act cycles. DKA determination time was our primary outcome, and secondary outcomes included the percentage of patients receiving IV placement and ED LOS. Process measures included the rate of use of POC testing and order panels. All measures were analyzed on statistical process control charts. RESULTS: Between January 2015 and July 2018, 783 patients with diabetes mellitus were evaluated for DKA. After all 4 interventions, DKA determination time decreased from 86 to 26 minutes (P , .001). In patients without DKA, IV placement decreased from 85% to 36% (P , .001). ED LOS decreased from 206 to 186 minutes (P = .009) in patients discharged from the hospital after DKA evaluation. POC testing and order panel use increased from 0% to 98% and 90%, respectively. CONCLUSIONS: Using quality-improvement methodology, we achieved a meaningful reduction in DKA determination time, the percentage of IV placements, and ED LOS.

Diabetic ketoacidosis in pediatric patients with type 1- and type 2 diabetes during the COVID-19 pandemic

“…The pediatric department in Wisconsin developed further steps to reduce complications for DKA through diagnosing DKA faster. POC tests (point of care), order panels, provider guidelines, and nursing guidelines reduced the time to determine DKA from 86 to 30 minutes [ 15 ]. Investing in structured education and guidelines for primary health care staff is an important step, particularly in times of COVID-19, to prevent complications in DKA diagnosis and therapy.…”

Standardized hospital management of pediatric diabetic ketoacidosis reduces frequency of low blood glucose episodes

“…Prior to this quality improvement initiative, our institution utilized a one IV fluid bag treatment approach to treat DKA, which required entry of new orders and pharmacy preparation of a new IV fluid bag for each change in the infused dextrose concentration (Table 1). This project's team had prior QI experience with DKA having previously collaborated to expedite the diagnosis of DKA in the emergency department using point of care testing for bicarbonate (HCO 3 ) 9 . Therefore, an automated‐electronic extraction process previously existed to monitor DKA patient outcomes, and the team reviewed the resultant data throughout this project.…”

“…This project's team had prior QI experience with DKA having previously collaborated to expedite the diagnosis of DKA in the emergency department using point of care testing for bicarbonate (HCO 3 ). 9 Therefore, an automated-electronic extraction process previously existed to monitor DKA patient outcomes, and the team reviewed the resultant data throughout this project. with DKA to our ED had a BG < 80 mg/dl while at our institution (Figure 1).…”

Cetoacidosis diabética: un cuadro de importancia en pediatría

“…10 Debemos tomar en cuenta que la cetoacidosis diabética es la causa de 1% de las admisiones hospitalarias al año, de éstas 5-28% se encuentran en las unidades de cuidados intensivos. 8,11 La incidencia de hospitalizaciones por cetoacidosis diabética continúa en aumento, en 2014 se encontró un registro en el número de hospitalizaciones totales de 188,965, de las cuales 11% eran pacientes menores de 17 años. 9…”