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Improving Emergency Department Management of Diabetic Ketoacidosis in Children

Shannon H Baumer-Mouradian1, Matthew P Gray2, Peter M Wolfgram2

  • 1Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin; and sbaumer@mcw.edu.

Pediatrics
|September 14, 2019
PubMed

Insights

Point-of-care testing significantly reduced diagnostic delays for pediatric diabetic ketoacidosis (DKA) and decreased unnecessary IV placements in emergency departments. This quality improvement initiative improved patient care and reduced hospital stays.

Area of Science:

  • Pediatric Emergency Medicine
  • Quality Improvement Science
  • Clinical Diagnostics

Background:

  • Diagnostic delays in pediatric emergency departments (ED) prolong length of stay (LOS) and lead to unnecessary interventions, particularly for patients with diabetes mellitus evaluated for diabetic ketoacidosis (DKA).
  • At baseline, DKA determination time was 86 minutes, with 61% of patients not meeting DKA criteria and 85% of those receiving unnecessary intravenous (IV) placement.
  • The study aimed to reduce DKA determination time to 30 minutes and IV placements in non-DKA patients to 20% using point-of-care (POC) testing.

Purpose of the Study:

  • To implement and evaluate the impact of a multi-faceted quality improvement initiative on DKA diagnosis and management in a pediatric ED.
  • To reduce the time from patient arrival to DKA diagnosis (determination time).
  • To decrease the rate of unnecessary IV line placement in patients ultimately not diagnosed with DKA.

Main Methods:

  • A plan-do-study-act (PDSA) methodology was employed to test four key interventions: POC testing, standardized order panels, provider guidelines, and nursing guidelines.
  • DKA determination time was the primary outcome measure, with secondary outcomes including IV placement rates and ED LOS.
  • Statistical process control charts were used to analyze all outcome and process measures.

Main Results:

  • Following the implementation of all four interventions, DKA determination time decreased significantly from 86 to 26 minutes (P < .001).
  • The percentage of patients without DKA who received IV placement dropped from 85% to 36% (P < .001).
  • Emergency department LOS for discharged patients after DKA evaluation decreased from 206 to 186 minutes (P = .009), and POC testing and order panel utilization increased to 98% and 90%, respectively.

Conclusions:

  • Quality improvement methodologies, including POC testing, effectively reduced DKA determination time, unnecessary IV placements, and ED LOS in pediatric patients.
  • The study demonstrated a successful, data-driven approach to optimizing diagnostic and treatment pathways in the pediatric ED.
  • These interventions highlight the potential for significant improvements in efficiency and patient care for diabetes-related emergencies.
Abstract

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