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Updated: Sep 9, 2025
Improving IV Insulin Administration in a Community Hospital
Published on: June 11, 2012
Improving Emergency Department Care for Children With Medium- and High-Risk Diabetic Ketoacidosis
Kelly R Bergmann1, M Jennifer Abuzzahab2, Vitaliy Perepelista3
1Department of Emergency Medicine, Children's Minnesota, Minneapolis, Minnesota.
Insights
This quality improvement initiative successfully increased the use of the 2-bag intravenous (IV) fluid system for pediatric diabetic ketoacidosis (DKA). The study enhanced treatment protocols, leading to wider adoption of this effective DKA management strategy.
Area of Science:
- Pediatric Endocrinology
- Critical Care Medicine
- Quality Improvement Science
Background:
- Diabetic ketoacidosis (DKA) is a serious complication of diabetes requiring prompt and effective management.
- The 2-bag intravenous (IV) fluid system has shown promise in improving DKA treatment outcomes, including shorter insulin duration and faster acidosis resolution.
- Optimizing treatment protocols for DKA in pediatric populations is crucial for improving patient care and outcomes.
Purpose of the Study:
- To increase the utilization of the 2-bag IV fluid system for pediatric patients with medium- or high-risk diabetic ketoacidosis (DKA).
- To enhance the timely administration of fluid and insulin therapies in pediatric DKA cases.
- To evaluate the impact of a quality improvement initiative on DKA treatment practices in tertiary care pediatric hospitals.
Main Methods:
- A multi-center quality improvement initiative was implemented across two tertiary care pediatric hospitals.
- Data were collected from January 2014 to December 2021, encompassing pre-initiative, post-initiative, and stability periods.
- Interventions included the development of a clinical practice guideline, staff education, and electronic medical record system updates, with analysis using statistical process control methods.
Main Results:
- The study identified 876 eligible pediatric DKA encounters.
- The utilization of the 2-bag IV fluid system significantly increased from 41.3% to 77.7%.
- No significant changes were observed in the time to isotonic fluid bolus, continuous insulin infusion, or the incidence of hypoglycemic events.
Conclusions:
- A comprehensive quality improvement initiative effectively increased the adoption of the 2-bag IV fluid system for pediatric DKA.
- The successful implementation involved a combination of clinical guideline refinement, nursing algorithm development, and targeted nursing education.
- These interventions demonstrate a successful strategy for improving evidence-based treatment protocols in pediatric DKA management.
Objectives:
The 2-bag intravenous (IV) fluid system for diabetic ketoacidosis (DKA) has been associated with shorter duration of insulin and faster resolution of acidosis. Our aims were to increase the use of 2-bag IV fluids among children with medium- or high-risk DKA treated at 2 tertiary care pediatric hospitals and to increase the proportion of children who receive timely administration of fluid and insulin treatments.
Methods:
We conducted a quality improvement initiative using data from January 1, 2014, to December 31, 2021, among patients 21 years or younger with medium- or high-risk DKA. The study spanned pre- and post-initiative periods and a stability period. Our interventions included development of a clinical practice guideline, education, and electronic medical record updates. Statistical process control methods were used to evaluate outcome changes.
Results:
We identified 876 eligible encounters. Age, sex, and the proportion of children with medium- or high-risk DKA were similar across study periods. A higher proportion of non-Hispanic Black children was observed in the stability period (26.3%) than the pre- (17.7%) and post-initiative (18.2%) periods. We observed an increase in 2-bag IV fluid use from an average of 41.3% to 77.7%. We did not observe changes in time to isotonic fluid bolus, continuous insulin, or 2-bag IV fluids. There was no change in hypoglycemic events.
Conclusion:
We increased the proportion of children with medium- or high-risk DKA treated with 2-bag IV fluids through a combination of interventions, including implementation and refinement of a clinical guideline, creation of a nurse algorithm, and nursing education.
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