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Improving Emergency Department Management of Diabetic Ketoacidosis in Children. Pediatrics 2019 10;144(4)

Date

09/14/2019

Pubmed ID

31515299

DOI

10.1542/peds.2018-2984

Scopus ID

2-s2.0-85072848463   4 Citations

Abstract

BACKGROUND: Diagnostic delays in the pediatric emergency department (ED) can lead to unnecessary interventions and prolonged ED length of stay (LOS), especially in patients with diabetes mellitus evaluated for diabetic ketoacidosis (DKA). At our institution, baseline DKA determination time (arrival to diagnosis) was 86 minutes, and 61% of patients did not meet DKA criteria. Subsequently, intravenous (IV) placement occurred in 85% of patients without DKA. We aimed to use point-of-care (POC) testing to reduce DKA determination time from 86 to 30 minutes and to reduce IV placements in patients without DKA from 85% to 20% over 18 months.

METHODS: Four key interventions (POC tests, order panels, provider guidelines, and nursing guidelines) were tested by using plan-do-study-act cycles. DKA determination time was our primary outcome, and secondary outcomes included the percentage of patients receiving IV placement and ED LOS. Process measures included the rate of use of POC testing and order panels. All measures were analyzed on statistical process control charts.

RESULTS: Between January 2015 and July 2018, 783 patients with diabetes mellitus were evaluated for DKA. After all 4 interventions, DKA determination time decreased from 86 to 26 minutes (P < .001). In patients without DKA, IV placement decreased from 85% to 36% (P < .001). ED LOS decreased from 206 to 186 minutes (P = .009) in patients discharged from the hospital after DKA evaluation. POC testing and order panel use increased from 0% to 98% and 90%, respectively.

CONCLUSIONS: Using quality-improvement methodology, we achieved a meaningful reduction in DKA determination time, the percentage of IV placements, and ED LOS.

Author List

Baumer-Mouradian SH, Gray MP, Wolfgram PM, Kopetsky M, Chang F, Brousseau DC, Frenkel MM, Ferguson CC

Authors

Shannon H. Baumer-Mouradian MD Assistant Professor in the Pediatrics department at Medical College of Wisconsin
David Brousseau MD Chief, Professor in the Pediatrics department at Medical College of Wisconsin
Catherine Ferguson MD Director, Associate Professor in the Pediatrics department at Medical College of Wisconsin
Peter M. Wolfgram MD Associate Professor in the Pediatrics department at Medical College of Wisconsin




MESH terms used to index this publication - Major topics in bold

Adolescent
Blood Glucose
Child
Child, Preschool
Delayed Diagnosis
Diabetes Mellitus, Type 1
Diabetic Ketoacidosis
Emergency Service, Hospital
Female
Fluid Therapy
Guidelines as Topic
Hospitals, Pediatric
Humans
Hypoglycemic Agents
Infant
Insulin
Length of Stay
Male
Patient Care Team
Point-of-Care Testing
Quality Improvement
Time-to-Treatment
Wisconsin
Young Adult