Evaluation of an Institution-Wide Guideline for Hyperglycemic Emergencies at a Tertiary Academic Medical Center

Beik, Nahal; Anger, Kevin E.; Forni, Allison; Bawa, Komal; Szumita, Paul M.

doi:10.1177/1060028013503111

Cited by 10 publications

(11 citation statements)

References 13 publications

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“…They found no difference in their primary outcome of hospital LOS. However, there was a decreased time to anion gap closure and a shorter ICU LOS in patients admitted to an ICU . Additionally, Bull et al .…”

Section: Discussionmentioning

confidence: 97%

“…Thus, there would be a higher probability of identifying episodes of hypoglycaemia. Similar studies did not find a difference in hypoglycaemic events, but their protocols called for every 2‐h monitoring and their definitions of hypoglycaemia varied from < 55 to 72 mg/dl . An Australian centre successfully utilised a standard 6 units/h insulin infusion rate with a mandatory dextrose infusion as serum glucose reached < 252 mg/dl .…”

Section: Discussionmentioning

confidence: 99%

“…Severity of illness and concomitant conditions, which may be confounding factors, was not assessed in our study. Finally, two studies included patients with HHS, which has a different pathogenesis, separate diagnostic criteria and higher mortality rate …”

Section: Discussionmentioning

confidence: 99%

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Impact of diabetic ketoacidosis management in the medical intensive care unit after order set implementation

Laliberte

Yeung

Gonzales

2017

International Journal of Pharmacy Practice

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Section: Discussionmentioning

confidence: 97%

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Impact of diabetic ketoacidosis management in the medical intensive care unit after order set implementation

Laliberte

Yeung

Gonzales

2017

International Journal of Pharmacy Practice

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“…Treatment of hyperglycemic crises is complex, typically involves use of high-risk medications such as intravenous (IV) insulin, and is commonly complicated by hypoglycemia (1,2). Due to the frequency of complications, health care systems are increasingly implementing standardized clinical protocols to help guide staff in the management of hyperglycemic crises (3–7). Despite implementation of a standardized protocol, our institution continued to experience a high incidence of complications.…”

Section: Describe the Specific Quality Gap Addressed Through The Initmentioning

confidence: 99%

Integration of Around-the-Clock Clinical Pharmacy Specialists Into the Critical Care Team Can Increase Safety of Hyperglycemic Crisis Management

et al. 2019

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IN BRIEF “Quality Improvement Success Stories” are published by the American Diabetes Association in collaboration with the American College of Physicians, Inc., and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes an effort to improve the safety of hyperglycemic crisis management at a Veterans Affairs Medical Center by making clinical pharmacy specialists available to the critical care team 24 hours/day.

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“…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)(7)(8)(9).…”

mentioning

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 an Institution-Wide Guideline for Hyperglycemic Emergencies at a Tertiary Academic Medical Center

Abstract: Implementation of an institutional guideline and order set for hyperglycemic emergencies decreased ICU LOS and time to anion gap closure, with no difference in rates of hypoglycemia.

Cited by 10 publications

References 13 publications

Impact of diabetic ketoacidosis management in the medical intensive care unit after order set implementation

Impact of diabetic ketoacidosis management in the medical intensive care unit after order set implementation

Integration of Around-the-Clock Clinical Pharmacy Specialists Into the Critical Care Team Can Increase Safety of Hyperglycemic Crisis Management

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

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