Improving Care for Pediatric Diabetic Ketoacidosis

Abstract

OBJECTIVE: We sought to create and implement recommendations from an evidence-based pathway for hospital management of pediatric diabetic ketoacidosis (DKA) and to sustain improvement. We hypothesized that development and utilization of standard work for inpatient care of DKA would lead to reduction in hypokalemia and improvement in outcome measures.METHODS: Development involved systematic review of published literature by a multidisciplinary team. Implementation included multidisciplinary feedback, hospital-wide education, daily team huddles, and development of computer decision support and electronic order sets. RESULTS:Pathway-based order sets forced clinical pathway adherence; yet, variations in care persisted, requiring ongoing iterative review and pathway tool adjustment. Quality improvement measures have identified barriers and informed subsequent adjustments to interventions. We compared 281 patients treated postimplementation with 172 treated preimplementation. Our most notable findings included the following: (1) monitoring of serum potassium concentrations identified unanticipated hypokalemia episodes, not recognized before standard work implementation, and earlier addition of potassium to fluids resulted in a notable reduction in hypokalemia; (2) improvements in insulin infusion management were associated with reduced duration of ICU stay; and (3) with overall improved DKA management and education, cerebral edema occurrence and bicarbonate use were reduced. We continue to convene quarterly meetings, review cases, and process ongoing issues with system-based elements of implementing the recommendations. CONCLUSIONS:Our multidisciplinary development and implementation of an evidence-based pathway for DKA have led to overall improvements in care. We continue to monitor quality improvement metric measures to sustain clinical gains while continuing to identify iterative improvement opportunities. Pediatrics 2014;134:e848-e856 Dr Koves drafted, wrote, and submitted the manuscript; developed the design for manuscript and metrics data definitions; interpreted the data; formatted the manuscript; facilitated contributions; developed the figures, tables, references, and reference formatting; and facilitated publication of the final version; she provided oversight for all aspects of the development of the diabetic ketoacidosis (DKA) clinical standard work package; Dr Leu made substantial contributions to the conception and revision of clinical guidelines, architected and updated clinical decision supports used to support the project, reviewed analysis of data, composed a portion of the original manuscript, and edited all of the final manuscript; Ms Spencer performed data analysis and statistical significance testing and contributed writing to the methods of evaluation, results, and analysis sections; Ms Popalisky contributed writing to the methods and discussion sections and assisted with review and revising drafts of the manuscript; Ms Drummond contributed to writing the methods and discussion sections...

Substantial reduction in hospital stay of children and adolescents with diabetic ketoacidosis after implementation of Clinical Practice Guidelines in a university hospital in Saudi Arabia

“…21 Also, Koves et al implemented an evidence-based clinical pathway for the management of pediatric DKA and compared 281 patients treated post implementation with 172 treated pre-implementation. 22 Their findings showed an overall improved DKA management and resulted in a reduced duration of ICU stay.…”

“…Our findings agree with Ganesh et al who investigated the outcome of management of DKA using a standard protocol and found that the length of stay in pediatric intensive care unit was 2.9 days; however, this was not compared with the data before using the standard protocol . Also, Koves et al implemented an evidence‐based clinical pathway for the management of pediatric DKA and compared 281 patients treated post implementation with 172 treated pre‐implementation . Their findings showed an overall improved DKA management and resulted in a reduced duration of ICU stay.…”

Adherence to a pediatric diabetic ketoacidosis protocol in children presenting to a tertiary care hospital

“…Due to the hyperosmolar state of DKA, children are also frequently volume‐depleted upon presentation to hospital . Because of the risk for significant morbidity and mortality associated with DKA, and because pediatric DKA is managed by a combination of primary care, emergency room physicians and by pediatric specialists, standardized treatment protocols are recommended and are widely used across North America . Many of these protocols recommend cautious use of fluid boluses in pediatric DKA, due to the risk for cerebral edema with increased fluid administration.…”

Exploring Value in Congenital Heart Disease: An Evaluation of Inpatient Admissions

“…In response to the need for value‐based care, there have been several important efforts to standardize clinical practice to reduce resource utilization while maintaining standard care . However, the applications of these expensive programs, framed predominantly by disease or procedure, are not guided by an understanding of baseline value .…”

“…In response to the need for value-based care, there have been several important efforts to standardize clinical practice to reduce resource utilization while maintaining standard care. [14][15][16][17] However, the applications of these expensive programs, framed predominantly by disease or procedure, are not guided by an understanding of baseline value. 18 Without this consideration, programmatic resources may be allocated towards standardization work with comparatively little or, paradoxically, more costly results.…”