Using Quality Improvement to Design and Evaluate an Outpatient Day Treatment Pathway for Pediatric Patients with...

Area of Science:

• Pediatric Endocrinology
• Diabetes Management
• Healthcare Delivery Models

Background:

• Hospitalization for insulin initiation in pediatric diabetes mellitus (DM) is not always necessary.
• Development of an outpatient day treatment pathway for select patients after emergency department (ED) evaluation.
• Focus on a pediatric, tertiary care academic medical center.

Purpose of the Study:

• To establish and evaluate an outpatient day treatment pathway for pediatric patients requiring insulin initiation.
• To identify eligibility criteria and barriers for successful implementation of the day treatment pathway.
• To assess the feasibility and effectiveness of managing new-onset or established DM in children without hospitalization.

Main Methods:

• A multidisciplinary team defined eligibility criteria (e.g., no diabetic ketoacidosis, age ≥3 years, plasma beta-hydroxybutyrate <1 mmol/L).
• Electronic medical record reviews and provider surveys identified exclusion reasons and barriers.
• Plan-do-study-act cycles refined the pathway, with statistical process control monitoring uptake.

Main Results:

• The pathway was launched in September 2020. Of 534 ED patients with DM needing insulin, 198 were eligible, and 65 (33%) completed the day treatment.
• Adjustments to the pathway (increased BOHB cutoff to 1.5 mmol/L, rapid-acting insulin option) significantly increased utilization from 24.4% to 41.1%.
• Key barriers included limited appointment availability, weekend presentations, and patient/family concerns.

Conclusions:

• Outpatient day treatment is a successful model for select pediatric patients with diabetes mellitus requiring insulin initiation.
• The model requires adaptable resources and clear, supportive communication for patients and families.
• Further optimization is needed to address persistent barriers and improve participation rates.