Impact of a critical pathway on inpatient management of diabetic ketoacidosis

https://doi.org/10.1016/S0168-8227(03)00143-8Get rights and content

Abstract

To assess the management of diabetic ketoacidosis (DKA) and evaluate if introduction of a critical pathway improves management, we studied adults admitted with DKA to the Medicine and Critical Care Services in a US teaching hospital. Patients admitted with DKA in 1997 before implementation of the critical pathway were the control group (n=72). In 1998, housestaff and nurses in the emergency department (ED) and on the General Medicine and Critical Care Services were instructed in the use of the critical pathway. Patients admitted with DKA during 1998 (n=77) were the intervention group. Length of stay (LOS), hospital cost, adherence to guidelines, and medical outcomes to be avoided were compared, and regression analyses were performed to correlate processes and outcomes of care. Mean LOS and variability in LOS decreased during the intervention period, especially in patients treated without endocrinology consultation (EC) (5.2±10.6 vs. 2.4±2.1 days, P=0.01), and hospital cost and variability in cost tended to decrease ($6441±15,204 vs. $3625±3478, P=0.24). More intervention subjects received the recommended intravenous fluid volume (88 vs. 71%, P=0.013), education in sick-day management (77 vs. 54%, P=0.006), and EC (38 vs. 21%, P=0.03). Insulin management was not changed. We conclude that implementation of a DKA critical pathway reduced practice variation and was associated with shorter LOS and a trend toward decreased cost. Some processes of care were improved but many require additional interventions.

Introduction

Diabetic ketoacidosis (DKA) is an acute metabolic complication of diabetes. It frequently requires hospitalization for treatment, and entails use of substantial health care resources. Mortality is more likely to occur if there is a serious intercurrent illness or if DKA is misdiagnosed, untreated, or undertreated [1], [2], [3]. In the US in 1994, DKA was the primary diagnosis for 89,000 hospital discharges and a listed diagnosis for 113,000 hospital discharges, with an average length of stay (LOS) of 4.5 days [4].

While there are published recommendations on how DKA should be treated [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], widely divergent treatment plans, hospital LOS, use of health care resources, and health care costs have been reported [15], [16], [17], [18], [19], [20]. Differences may be due in part to clinical uncertainty and differences in experience and expertise in the treatment of DKA. On admission to the General Medicine and Critical Care Services at a teaching hospital, treatment is usually initiated by junior medical staff. Diabetes specialty teams are not involved unless consulted. Hospital management of DKA has been reported to be suboptimal in a UK teaching hospital in spite of availability of clinical guidelines and biannual lectures to the junior medical staff [21]. Shorter LOS has been reported for patients managed with shorter interval from presentation to administration of a depot of suspended insulin [16]. DKA care by endocrinologists compared to generalists has been reported to result in shorter hospital stays and lower charges in many [16], [17], [18] but not all populations [19].

We hypothesized that clinical uncertainty and variation in the management of DKA could be decreased by providing a DKA critical pathway. We further hypothesized that a DKA critical pathway could promote efficiency in the care process, decrease LOS, decrease cost, and improve outcomes. Critical pathways are tools that have emerged with the growth of managed care. They delineate desired processes and outcomes during the course of a patient's hospitalization, including pharmacologic and non-pharmacologic treatments from time of admission to discharge. Thus they provide a comprehensive approach to patient management and provide a framework for data collection to determine how often and why patients' courses differ from expected. While critical pathways have been developed and implemented, their effectiveness remains uncertain due to lack of published studies [22].

The purpose of this study was to evaluate the management of DKA and the outcomes of treatment before and after implementation of a DKA critical pathway in a US teaching hospital.

Section snippets

Patients and methods

The study was designed as an observational trial: control patients were treated in the year prior to the introduction of the critical pathway and intervention patients were treated in conjunction with implementation of the critical pathway. We chose such a design for two reasons: first, we felt that the study needed to be conducted at a single site. Treatment of DKA varies tremendously across sites and across-site variation might easily overwhelm and obscure any potential impact of the critical

Results

ED logs and finance data identified 89 patients admitted with the diagnosis of DKA in 1997. Of these, 72 were included in the control group. Those excluded were patients transferred from other institutions where they had initially been treated for DKA (seven patients) and those admitted to services other than General Medicine or Critical Care Medicine (three to Gastroenterology, six to Nephrology, and one to Oncology). The critical pathway for the inpatient management of DKA was implemented

Discussion

This study assessed the characteristics, treatment, and outcomes of patients admitted with DKA to a US teaching hospital before and after the implementation of a critical pathway for the inpatient management of DKA. After the implementation of the DKA critical pathway, we observed decreased variability in LOS and cost, trends towards decreased LOS and cost, and a significantly lower mean and median LOS in patients treated without EC.

The decrease in LOS was associated with recommended fluid

Acknowledgements

This study was supported by a research grant from the Endocrine Fellows Foundation and from the National Institutes of Health Grant DK-20572 to the Michigan Diabetes Research and Training Center. The authors would like to thank Sandy Kewman, Ellen Bunting, Charles Watts and Maureen Thompson for their help and support in conducting this study. Special thanks also go to the University of Michigan Emergency Medicine and Internal Medicine housestaff and nurses whose participation and record keeping

References (27)

  • M.I. Wiggam et al.

    Treatment of diabetic ketoacidosis using normalization of blood 3-hydroxybutyrate concentration as the endpoint of emergency management

    Diabetes Care

    (1997)
  • R. Matz

    Managing fluid abnormalities in uncontrolled diabetes mellitus

    Journal of Critical Illness

    (1997)
  • R. Matz

    Coping with electrolyte imbalances in uncontrolled diabetes mellitus

    Journal of Critical Illness

    (1997)
  • Cited by (34)

    • Examining the “Killer K” of Diabetic Ketoacidosis at a Tertiary Care Hospital: An Exploratory Study

      2016, Canadian Journal of Diabetes
      Citation Excerpt :

      Our results should also be interpreted with caution because of the comparatively modest numbers, and the possible effects of differences in training levels and expertise of the trainees involved in DKA management. Nevertheless, the patterns of care and the characteristics of our population with DKA were similar to those of other teaching hospitals, and the rate of hypokalemia in our study was comparable to that of the majority of previous studies (4–7,10,11). Although our findings may not be generalizable to community hospital settings, we believe our findings may be useful to other academic centres and will assist in efforts to examine their own DKA practices in areas that are in need of improvement.

    • Use of a standardised diabetic ketoacidosis management protocol improved clinical outcomes

      2014, Diabetes Research and Clinical Practice
      Citation Excerpt :

      Several health professionals are usually involved in the management of DKA especially after hours using variable regimens. Over the last decade, efforts to standardise DKA management have been shown in other countries to have a positive impact on patient care [5–7] but it has not been reported in an Australian setting. We aimed to analyse whether using a standardised protocol improves clinical outcomes in the acute management of DKA at a tertiary teaching hospital in Australia.

    View all citing articles on Scopus
    View full text