P0150 - Standardizing Hospital Management of Pediatric Diabetic Ketoacidosis in order to Reduce Iatrogenic Low Blood Glucose Episodes

Background: IV insulin infusions, the standard treatment for pediatric diabetic ketoacidosis (DKA), may lead to iatrogenic hypoglycemia. Concern for and occurrence of iatrogenic hypoglycemia in DKA patients causes slowing or discontinuation of an IV insulin infusion, which ultimately prolongs DKA therapy. Baseline data at our institution demonstrated 53% of patients receiving IV insulin for DKA management experienced a blood glucose (BG) < 100mg/dL necessitating slowing of insulin therapy and 32% experienced a BG < 80mg/dL necessitating premature discontinuation of insulin therapy. We theorized that standardized DKA management and hypoglycemia prevention strategies would prevent BG levels from falling below these actionable thresholds.

Objective: In patients receiving IV insulin for DKA management, we aimed to decrease the rate of BG < 100mg/dL by 20% and BG < 80mg/dL by 10% within 24 months.
Methodology: Multiple interventions linked to key drivers were tested using plan-do-study-act cycles including a standardized DKA guideline incorporating the two-bag fluid system, order panels, frequent blood glucose monitoring, and provider and nursing education. Patients were included if they presented with a chief complaint of hyperglycemia, blood sugar problem, or diabetes and had DKA (bicarbonate level < 15). The primary outcomes were (1) the percent of DKA patients with a BG < 100mg/dL and (2) the percent of DKA patients with a BG < 80mg/dL while on IV insulin. The process measure was the order panel utilization rate. Balancing measures included: emergency department (ED) length of stay, time to correction of acidosis (time to bicarbonate > 17), and admission rates. All outcomes were analyzed using statistical process control charts.
Results &

Discussion: From January 2017 through April 2020, 411 patients had confirmed DKA and received IV insulin in the ED or the hospital’s acute care unit. Following our interventions, the percent of patients with a BG < 100mg/dL improved from 53% to 40% (Figure 1), and the percent of patients experiencing a BG < 80mg/dL improved from 32% to 22% (Figure 2). Order panel utilization rate remained at 97% in the ED and 70% on the acute care floor throughout this time. There was no change in balancing measures. These interventions potentially eliminated the need to slow insulin therapy in 34 DKA patients and prematurely discontinue insulin therapy in 20 DKA patients.

Conclusions: Use of quality improvement methodology and standardized DKA management resulted in a meaningful reduction in the percent of patients with iatrogenic hypoglycemia episodes while on IV insulin for DKA management.