Fewer Kids Hospitalized For Diabetic Ketoacidosis After Quality-Improvement Initiative

Implementation of an evidenced-based treatment guideline by a multidisciplinary team appears to have significantly cut the number of pediatric hospitalizations for low-risk diabetic ketoacidosis (DKA), researchers report.

"Our physicians had some reservation that this may lead to some children returning to the emergency department (ED) 1-2 days later even more ill than at initial presentation," Dr. Kelly R. Bergmann of Children's Minnesota, in Minneapolis, told Reuters Health by email. "But we didn't see that at all. I think that's a testament both to our ED care and the follow-up children receive from our endocrine clinic."

Children who present to the ED with mild acidosis, established type 1 diabetes, knowledge of sick-day management and ability to perform home care, and no social conditions or comorbid illness that would impede discharge can be considered low risk and managed at home with outpatient care, but uncertainty remains regarding optimal treatment strategies.

Dr. Bergmann's team included experts in the management of children with type 1 diabetes, a health economist and statistician, and a member of the hospital's family advisory council. Together they developed an evidence-based guideline and provided an update to the electronic medical record (EMR) order set, updates to ED physicians and stakeholders, and education to nurses with the aim of reducing hospitalization rates by 10% for children presenting to the ED with low-risk DKA.

The hospitalization rate decreased from 74% before implementation of the quality-improvement initiative to 55% after implementation (P=0.011), which corresponded to 13 potential hospitalizations avoided and surpassed the goal, the team reports in Pediatrics.

The median ED length of stay increased significantly from 215 minutes before to 241 minutes after implementation.

The number of children with ED revisits within 3 days did not change significantly after implementation of the initiative.

The adjusted mean charges among hospitalized children were $13,022 higher than among children discharged from the ED.

"As with any quality-improvement initiative, a main hurdle is getting physician buy-in," Dr. Bergmann said. "We were asking our pediatric emergency physicians to change the way they think about management of diabetes-related complications. Our physicians are so passionate about providing the best care for all children. We needed to show them the data on a frequent basis to really show that children and families benefit from this model of care of diabetic emergencies."

"Children with diabetes often develop DKA simply due to insulin omission," she added. "Our state legislature is currently working on a bill to increase access to insulin for diabetics. Even though we reduced hospitalizations for a subset of children with DKA, passing a bill that would provide increased access to insulin would likely have a broader impact and reduced ED visits and hospitalizations for even more children and adolescents with diabetes."

—Will Boggs MD

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