Evaluation of Ward Management of Diabetic Ketoacidosis

Outcomes of diabetic ketoacidosis in a tertiary centre with restricted intensive care unit bed capacity

BACKGROUND

Diabetic ketoacidosis (DKA) is an acute metabolic condition, sometimes requiring admission to an intensive care unit (ICU).

AIMS

To investigate the outcomes of DKA patients admitted to a hospital with restricted ICU capacity.

METHODS

We included all DKA patients above age 18 who were admitted to a tertiary hospital during 2004-2017. We conducted multivariate logistic regression analysis adjusted for ICU bed availability to analyse parameters associated with ICU admission, and a composite outcome of mortality, DKA recurrence and mechanical ventilation.

RESULTS

Among 382 DKA patients in our cohort, 94 (24.6%) were admitted to the ICU. The in-hospital mortality was 4.7%. Low bicarbonate (<10 mmoL/L) and pH (<7) levels at presentation were associated with ICU admission (P < 0.001 for both). In multivariate models availability of beds in the ICU was not associated with ICU admission, mortality or DKA recurrence of any type.

CONCLUSION

In a setting of limited ICU capacity, DKA treatment does not necessarily require admission to the ICU. When the rising rates of diabetes mellitus and the associated elevated rates of DKA are taken into account, our results highlight the importance of including step-down units when devising local protocols for care of these patients.

Evaluation of a Diabetic Ketoacidosis Order Set in Adults With Type 1 and Type 2 Diabetes at a Tertiary Academic Medical Centre: A Retrospective Chart Audit

OBJECTIVE

To assess safety and efficacy compared to a historical cohort. Clinical practice guidelines recommend that patients with diabetic ketoacidosis (DKA) be treated with a standardized protocol. We created a multifaceted order set to promote best-practice management of DKA.

METHODS

We performed a retrospective cohort study of admissions to internal medicine for DKA in adults during a 4.5-year period; 2.25 years before and after order-set initiation. Groups were compared using independent samples t tests and Pearson chi-square or Fisher exact test (categorical data). The Mann-Whitney U test was used for continuous data not normally distributed.

RESULTS

The order-set cohort consisted of 47 admissions, 72.3% with type 1 and 27.7% with type 2 diabetes. The historical cohort consisted of 59 admissions, 69.5% with type 1 and 30.5% with type 2 diabetes. There were no significant differences in initial laboratory values between patients with type 1 and type 2 diabetes in both cohorts. The median length of hospital stay approached significance in the order-set cohort: 3.53 days (2.5 to 5.1); in the historical cohort, the median length of stay was 4.6 days (2.44 to 8.99) (p=0.102).

CONCLUSION

A standardized DKA order set was as effective and safe in type 1 and type 2 diabetes as individual physician management in an academic care setting. Further study is needed to assess its value in community hospital settings with less expertise and fewer diabetes specialty services.

Hospital Guidelines for Diabetes Management and the Joint Commission-American Diabetes Association Inpatient Diabetes Certification

BACKGROUND

The Joint Commission Advanced Inpatient Diabetes Certification Program is founded on the American Diabetes Association's Clinical Practice Recommendations and is linked to the Joint Commission Standards. Diabetes currently affects 29.1 million people in the USA and another 86 million Americans are estimated to have pre-diabetes. On a daily basis at the Medical University of South Carolina (MUSC) Medical Center, there are approximately 130-150 inpatients with a diagnosis of diabetes.

METHODS

The program encompasses all service lines at MUSC. Some important features of the program include: a program champion or champion team, written blood glucose monitoring protocols, staff education in diabetes management, medical record identification of diabetes, a plan coordinating insulin and meal delivery, plans for treatment of hypoglycemia and hyperglycemia, data collection for incidence of hypoglycemia, and patient education on self-management of diabetes.

RESULTS

The major clinical components to develop, implement, and evaluate an inpatient diabetes care program are: I. Program management, II. Delivering or facilitating clinical care, III. Supporting self-management, IV. Clinical information management and V. performance measurement. The standards receive guidance from a Disease-Specific Care Certification Advisory Committee, and the Standards and Survey Procedures Committee of the Joint Commission Board of Commissioners.

CONCLUSIONS

The Joint Commission-ADA Advanced Inpatient Diabetes Certification represents a clinical program of excellence, improved processes of care, means to enhance contract negotiations with providers, ability to create an environment of teamwork, and heightened communication within the organization.

Predictors and treatment outcome of hyperglycemic emergencies at Jimma University Specialized Hospital, southwest Ethiopia

Background

Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) commonly known as hyperglycemic emergencies are the two most common life-threatening acute metabolic complications of diabetes. The objective of this study is to assess predictors and treatment outcome of hyperglycemic emergencies (HEs) among diabetic patients admitted to Jimma University Specialized Hospital (JUSH).

Methods

It is a three year retrospective review of medical records of patients admitted with HEs at JUSH. Patient demographics, admission clinical characteristics, precipitants, insulin used and treatment outcomes were extracted. Statistical analysis was done using student’s t test, Chi square test, and binary logistic regression with level of α set at 0.05. Statistical significance was considered for variables with p < 0.05.

Results

Complete data was available for 163 out of 421 patients admitted with HEs. The majority (62.6 %) were males. Mean age of patients was 36.6 ± 15.9 years. About 64 % of patients had type 1 diabetes. About 93 % of the participants developed DKA. The most common precipitants of HEs were infections 95 (59 %), non-compliance to medications 52 (32.3 %), and newly diagnosed diabetes 38 (23.6 %). Recurrent hyperglycemia, hypoglycemia and ketonuria occurred in 88 (54 %), 34 (20.9 %) and 31 (20.5 %) patients respectively. Mean amount of insulin used and duration of treatment till resolution of DKA were 136.85 ± 152.41 units and 64.38 ± 76.34 h respectively. The median length of hospital stay was 6 days. Mortality from HEs was 16 (9.8 %). Admission serum creatinine >1.2 mg/dL (P = 0.018), co-morbidity (P < 0.001) and sepsis (P = 0.014) were independent predictors of HEs mortality.

Conclusions

Infections, non-compliance and new onset diabetes were the most common precipitants of HEs. Length of hospital stay and mortality were high. High use of insulin, recurrent hyperglycemia, hypoglycemia, and ketonuria were common during HEs management. Elevated serum creatinine, sepsis and co-morbidity are independent predictors of HEs mortality.