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Variations in Management and Clinical Outcomes for Children With Diabetic Ketoacidosis in an Academic Pediatric
John Nathan Freeman1, Callie Giroux2, Timothy King3
1From the Division of Pediatric Emergency Medicine, Department of Pediatrics.
Insights
Pediatric diabetic ketoacidosis (DKA) management varied significantly between community and pediatric emergency departments. Community sites showed deviations from evidence-based guidelines, leading to longer treatment times for DKA patients.
Area of Science:
- Pediatric Emergency Medicine
- Endocrinology
- Quality Improvement Science
Background:
- Diabetic ketoacidosis (DKA) is a serious complication of diabetes in children.
- Standardized, evidence-based guidelines exist for DKA management.
- Variations in care delivery may impact patient outcomes.
Purpose of the Study:
- To compare the initial management of pediatric DKA patients presenting to community emergency departments (OSH) versus a tertiary pediatric emergency department (PED).
- To identify variations in adherence to evidence-based guidelines.
- To compare clinical outcomes between the two settings.
Main Methods:
- Retrospective study of pediatric patients (≤18 years) with DKA over 3 years.
- Comparison of treatments including fluid management, insulin, and sodium bicarbonate.
- Analysis of clinical outcomes such as time to anion gap correction, insulin infusion, and hospital discharge.
Main Results:
- OSH patients presented with more severe acidosis and larger anion gaps.
- OSH patients were more likely to receive fluid boluses, sodium bicarbonate, and IV bolus insulin.
- OSH patients had longer times for anion gap correction, insulin infusion, and hospital discharge.
- Incidence of hypokalemia, hypoglycemia, cerebral edema, and mortality were similar between groups.
Conclusions:
- Significant variations exist in pediatric DKA management between OSH and PED settings.
- OSH management often deviated from evidence-based pathways.
- Statewide quality improvement initiatives are recommended to standardize care and improve outcomes for pediatric DKA patients.
Objectives:
Our objectives were to characterize variations from standardized, evidence-based guidelines in the management of pediatric patients with diabetic ketoacidosis (DKA) based on initial presentation to a tertiary pediatric emergency department (PED) versus a community emergency department (OSH) and compare clinical outcomes.
Methods:
We conducted a retrospective study on children 18 years and younger with DKA who presented to an OSH or PED over a 3-year period. Treatments monitored for variation included intravenous fluid management, insulin delivery, and sodium bicarbonate administrations. Clinical outcomes included time to anion gap correction and on insulin infusion, hypokalemia, hypoglycemia, rapid serum glucose decline, cerebral edema, mechanical ventilation, mortality, and time from initial presentation to hospital discharge.
Results:
Children with DKA who presented to an OSH (n = 250) were more acidotic (pH 7.11 vs. 7.13, P = 0.001) and had larger anion gaps (28.8 vs. 25.5, P < 0.001) compared with children presenting to the PED (n = 237). The OSH patients were more likely to receive larger fluid boluses (>20 cc/kg or >1000 ml, 43% vs. 4%, P < 0.001), sodium bicarbonate (5% vs. 0%, P < 0.001), and intravenous bolus insulin (28% vs. 0%, P < 0.001). The OSH group were less likely to be started on maintenance intravenous fluids (70% vs. 99%, P < 0.001) or receive potassium in maintenance intravenous fluids (14% vs. 42%, P < 0.001). The OSH group had longer anion gap correction times (754 vs. 541 mins, P < 0.001), insulin infusion times (1018 vs. 854 min, P = 0.003), and times to hospital discharge (3358 vs. 3045 mins, P < 0.001). Incidence of hypokalemia, hypoglycemia, rapid glucose decline, cerebral edema, and deaths were similar between the 2 groups.
Conclusions:
Our study demonstrated significant variations in the initial management of pediatric DKA patients by OSH facilities that deviated from an evidence-based treatment pathway utilized by a PED. Statewide quality improvement initiatives could help improve the overall clinical care provided to pediatric DKA patients.
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