National survey of the management of Diabetic Ketoacidosis (DKA) in the UK in 2014

Abstract

2 Novelty Statementa) In 2013 a revised version of national guidance on the management of DKA was published, however there are no data to show that these recommendations actually work b) This is the largest national survey on the management of DKA c) Most patients developed hypokalaemia and over 25% developed hypoglycaemia. There were also significant issues with care processes d) The management of DKA will need to change to prevent hypokalaemia but will necessitate a shift in where patients are cared for. However, as a result of moving to a High Dependency or Intensive Care environment, care processes may improve.3 Abstract AimsOutcomes for the management of diabetic ketoacidosis (DKA) remain largely unstudied. In a national survey we examined outcomes of adult patients presenting with DKA in 2014, mapped against accepted UK national guidance. MethodsData were collected in a standardised form covering clinical, and biochemical, outcome, risk, and discharge planning. The form was sent to all UK diabetes specialist teams (n=220). Anonymised data were collected on 5 consecutive patients admitted with DKA between 1.5.14 and 30.11.14 Results 283 forms were received (n=281 patients), from 72 hospitals, 71.4% used the national guidelines. 7.8% of cases occurred in existing inpatients. 6.1% of admissions were newly diagnosed diabetes. 33.7% of patients had had at least 1 episode of DKA in the preceding year. The median time to starting 0.9% sodium chloride and intravenous insulin was 41.5 minutes and 60 minutes respectively. Median time to resolution was 18.7 hours, and median length of hospital stay was 2.6 days. Significant adverse biochemical outcomes occurred; with 27.6% of patients developing hypoglycaemia and 55% reported hypokalaemia. There were also significant issues with care processes.Initial nurse led observations were well carried out, but subsequent patient monitoring remained suboptimal. Most patients were not seen by a member of 4 the diabetes specialist team during the first 6 hours, but 95% were seen before discharge.A significant minority of discharge letters to primary care did not contain necessary information. ConclusionDespite widespread adoption of national guidance, several areas of DKA management are suboptimal, being associated with avoidable biochemical and clinical risk.

A reaudit of the management of diabetic ketoacidosis after the introduction of a local protocol based on the JBDS guidelines: then and now

“…There were seven (21%) recorded episodes of hypoglycaemia, which is an increase from the audit cycle 1 (10%) but not worse than the national average of 26.7% reported by Dhatariya et al 4 Potassium should be measured and replaced within at least the second hour of admission. Seventeen patients (51%) received potassium replacement within 2 hours of admission (range 2-480 min).…”

“…This is also better than the national average for hypokalaemia (67%) noted at 24 hours of DKA treatment. 4 Ketosis had resolved by 24 hours in >90% of cases across both audit cycles (Table 1). Median time to resolution of ketosis was 12 hours (mean 12.2 hours) compared with a median of 11 hours (mean 11.1 hours) in audit cycle 1.…”

“…This is similar to the higher reported values in the National DKA survey of 7.8% developing DKA during their inpatient stay. 4 In the National Diabetes Inpatient Audit (NaDIA) 2016, 4.4% of patients with type I diabetes developed DKA during their hospital stay. 5 These events of in-hospital DKA are reported as serious incidents and work is ongoing to reduce the risk of insulin omission and the appropriate management of hyperglycaemia in hospital.…”

“…Where possible, outcome end points will be compared against the national average, as stated in the national survey by Dhatariya et al in 2014, 4 and against the audit data from both 2012 immediately after the new guidelines and chart and 2010 prior to the introduction of the local protocol. A summary of results across audit cycles 1 and 2 can be found in Table 1.…”

Blood Ketones: Measurement, Interpretation, Limitations, and Utility in the Management of Diabetic Ketoacidosis

“…While in several previous studies DKA was the presenting feature of type 1 diabetes in up to 30% of cases [11,[21][22][23][24][25], recent data from national surveys in the UK have reported that DKA was the first presentation of type 1 diabetes in adults or adolescents in 3-6% of cases only [26,27]. In addition, the data from the adult survey of over 280 admissions with DKA also showed that mortality was lower than previously reported, with no deaths in the 2016 data, compared with a mortality of 3.9% and 1.8% in UK populations described previously, and 1.7% mortality described recently in a cohort from China [28][29][30].…”