Root cause analysis of diabetic ketoacidosis admissions at a tertiary referral pediatric emergency department in North India

Abstract

Objectives:To identify system-based factors contributing to Emergency Department (ED) admissions of children with diabetic ketoacidosis (DKA) and related complications with emphasis on parental and physician awareness and prereferral management.Materials and Methods:A prospective observational root cause analysis study of all consecutive admissions of children with DKA to pediatric ED of a tertiary care referral hospital in northern India over a period of 1 year (July 2010–June 2011). Prehospital, health-care system, referral, follow-up, and continuum of care related details were obtained through direct interview of parents and physicians and/or field observations for all enrolled children.Results:Of the 30 children enrolled, 26 (86.6%) were referrals; 16 (61.5%) from first, 7 (26.9%) from second, and 3 (11.5%) from third health-care facility. More than half (n [%], 18 [60%]) had new onset diabetes and belonged to lower socioeconomic strata. Twenty-two (73.3%) were complicated DKA; shock (n [%], 19 [63%]), hypokalemia (n [%], 11 [36%]), and CE (n [%], 3 [10%]) were the most common complications. Most parents were ignorant of diabetes, its symptoms or complicating DKA. Nearly, half of the cases remained undiagnosed (n = 11) at first contact health-care facility; more so for new onset as compared to known diabetes (9/18 vs. 2/8; P = 0.022). The referring hospitals had limited facilities for rapid blood glucose estimation (n [%], 12 [40%]), blood gas analysis (n [%], 6 [20%]) and insulin infusion. On univariate analysis, patients with missed/delayed diagnosis more often had severe and complicated DKA.Conclusion:Parental ignorance, lower socioeconomic status, lack of clinical experience, and limited primary health-care facilities were root causes for severe and complicated DKA.

0.9% saline versus Plasma-Lyte as initial fluid in children with diabetic ketoacidosis (SPinK trial): a double-blind randomized controlled trial

“…The severity, complications, morbidity, and mortality associated with DKA in LMIC are higher than that reported from the West. The putative reasons include lower socioeconomic status, missed or delayed diagnosis in new onset DM, poor adherence to therapy in known TIDM, and inadequate pre-referral optimization with fluids and insulin [16, 17]. These are further compounded by lack of follow-up and continuum of care among known TIDM as reflected by the high HbA1c levels in the present study indicating poor glycemic control.…”

“…Prolonged uncorrected dehydration/hypovolemia and inadequate fluids in such children aggravates the risk for AKI [16]. This is reflected in the fact that more than half (54.5%) had AKI (stages 2 and 3) at admission itself.…”

“…Pediatric DKA especially in low-middle income countries (LMIC) is associated with higher rate of complications due to poor socioeconomic status, non-compliance to therapy, associated comorbidities like malnutrition, sepsis and inadequate treatment at first contact healthcare facility [16–18]. Uncorrected dehydration increases the risk of AKI in these children.…”

Treatment Outcome of Diabetic Ketoacidosis Among Patients Atending General Hospital in North-West Ethiopia: Hospital Based Study

“…The main stay therapy of DKA relies in the correction of hyperglycemia with the administration of insulin. However, the initiation and continuation of adequate amount of insulin depends on the level of expertise that the professional bears which might affect the rapid identification of DKA (34).…”

Ketoacidosis as a presenting symptom of diabetes in a eighteen month old infant: a case report

“…Diabetes manifesting as ketoacidosis, its identification and prompt management is crucial. [13][14][15] Authors have reported one such patient experience. The prompt initiation of Insulin, rehydration, antibiotics corrected the clinical picture, the baby was able to take routine food, amiable, normal respiration and playful.…”