Reducing Diabetic Ketoacidosis Intensive Care Unit Admissions Through an Electronic Health Record-Driven, Standardized Care Pathway

Abstract

Diabetic ketoacidosis (DKA) is a common condition, with wide variation in admission location and clinical practice. We aimed to decrease intensive care unit (ICU) admission for DKA by implementing a standardized, electronic health record-driven clinical care pathway that used subcutaneous insulin, rather than a continuous insulin infusion, for patients with nonsevere DKA. This is a retrospective, observational preintervention to postintervention study of 214 hospital admissions for DKA that evaluated the effect of our intervention on clinical, safety, and cost outcomes. The primary outcome was ICU admission, which decreased from 67.0% to 41.7% (p < .001). Diabetes nurse educator consultation increased from 45.3% to 63.9% (p = .006), and 30-day Emergency Department (ED) return visit decreased from 12.3% to 2.8% (p = .008). Time to initiation of basal insulin increased from 18.19 ± 1.25 hours to 22.47 ± 1.76 hours (p = .05) and reopening of the anion gap increased from 4.7% to 13.9% (p = .02). No changes in ED length of stay (LOS), hospital LOS, hypoglycemia, treatment-induced hypokalemia, 30-day hospital readmission, or inpatient mortality were observed. The implementation of a standardized DKA care pathway using subcutaneous insulin for nonsevere DKA resulted in decreased ICU use and increased diabetes education, without affecting patient safety.

Creation of an Inflammatory Bowel Disease Referral Pathway for Identifying Patients Who Would Benefit From Inflammatory Bowel Disease Specialist Consultation

“…There are numerous examples of successfully applying care pathways through the electronic medical record in other fields of medicine, including in oncology, infectious diseases, endocrinology, and primary care. 71-73 Similar implementation schemes have also been shown to improve the management of anemia in pediatric patients with IBD. 74 These prior efforts could serve as a critical foundation for future implementation of our findings.…”

Bicarbonate as a predictor of successful insulin transition in critically ill patients with diabetic ketoacidosis: A retrospective cohort study

“…All patients were treated according to a standardized DKA protocol developed following ADA guidance. 4,19 Patients admitted through the emergency room who had a blood glucose of >250 mg/ dL, a bicarbonate of ≤16 mEq/L, and a pH <7.3 on an arterial or venous blood gas or a glucose of >250 mg/dL, a bicarbonate of ≤18 mEq/L, and an anion gap >12 from a basic or complete metabolic panel alerted providers the diagnosis of DKA. If patients were transferred from an outside facility, the diagnosis of DKA was confirmed using the same parameters through outside documentation review.…”

<strong>COVID-19: Considerations for Children and Adolescents with Diabetes</strong>

“…In regions where hospitals are overburdened with COVID-19 care, children with new-onset T1D without DKA can be easily managed without hospitalization with prompt initiation of insulin. Even non-severe DKA may respond well to closely supervised initiation of subcutaneous rapid-acting insulin either in the emergency room or outpatient department, thus avoiding admission into the intensive care unit besieged by COVID-19 (30). This is especially important for countries with poor healthcare infrastructure and are under severe resource crunch during the COVID-19 pandemic.…”