Comparison of outcomes and costs between adult diabetic ketoacidosis patients admitted to the ICU and step-down unit

Hyperglycemic Crises in Adults With Diabetes: A Consensus Report

The American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD), Joint British Diabetes Societies for Inpatient Care (JBDS), American Association of Clinical Endocrinology (AACE), and Diabetes Technology Society (DTS) convened a panel of internists and diabetologists to update the ADA consensus statement on hyperglycemic crises in adults with diabetes, published in 2001 and last updated in 2009. The objective of this consensus report is to provide up-to-date knowledge about the epidemiology, pathophysiology, clinical presentation, and recommendations for the diagnosis, treatment, and prevention of diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) in adults. A systematic examination of publications since 2009 informed new recommendations. The target audience is the full spectrum of diabetes health care professionals and individuals with diabetes.

Hyperglycaemic crises in adults with diabetes: a consensus report

The American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD), Joint British Diabetes Societies for Inpatient Care (JBDS), American Association of Clinical Endocrinology (AACE) and Diabetes Technology Society (DTS) convened a panel of internists and diabetologists to update the ADA consensus statement on hyperglycaemic crises in adults with diabetes, published in 2001 and last updated in 2009. The objective of this consensus report is to provide up-to-date knowledge about the epidemiology, pathophysiology, clinical presentation, and recommendations for the diagnosis, treatment and prevention of diabetic ketoacidosis (DKA) and hyperglycaemic hyperosmolar state (HHS) in adults. A systematic examination of publications since 2009 informed new recommendations. The target audience is the full spectrum of diabetes healthcare professionals and individuals with diabetes.

A systematic review and meta-analysis comparing outcomes between using subcutaneous insulin and continuous insulin infusion in managing adult patients with diabetic ketoacidosis

BACKGROUND

The purpose of this systematic review and meta-analysis was to synthesize the current literature to determine the safety and efficacy of using subcutaneous insulin compared to an intravenous (IV) insulin infusion in managing diabetic ketoacidosis (DKA).

METHODS

We searched Ovid-Medline, EMBASE, SCOPUS, BIOSIS and CENTRAL from inception to April 26, 2024. Randomized controlled trials (RCTs) and observational studies that assessed the use of subcutaneous compared to intravenous insulin for the treatment of mild to moderate DKA were included. Data extraction and quality assessment were performed by two independent reviewers and disagreements were resolved through further discussion or by a third reviewer. The Cochrane Risk of Bias tool version 2.0 was used to evaluate the RCTs and the Risk of Bias in Non-randomized Studies of Interventions (ROBINS)-I tool was used to evaluate the observational studies. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. Meta-analyses were conducted using random-effects models. We followed the PRISMA guidelines for reporting our findings.

RESULTS

Six RCTs (245 participants) and four observational studies (8444 patients) met our inclusion criteria. Some studies showed a decreased length of stay (Mean Difference [MD] in days: -0.39; 95% CI: -2.83 to 2.08; I2: 0%) among individuals treated with subcutaneous insulin compared to intravenous insulin. There was no difference in the risk of all-cause mortality, time to resolution of DKA (MD in hours: 0.17; 95% confidence interval [CI]: -3.45 to 3.79; I2: 0%) and hypoglycemia (Risk Ratio [RR]: 1.02; 95% CI: 0.88 to 1.19; I2: 0%) between the two groups.

CONCLUSION

Treatment of DKA with subcutaneous insulin may be a safe and effective alternative to IV insulin in selected patients. The limited available evidence underscores the need for further studies to explore optimal dosing, patient selection criteria and long-term outcomes.

Safety and Effectiveness of a Standardized Intravenous Insulin Infusion Order Set for Managing Uncontrolled Hyperglycemia Outside the Intensive Care Unit

BACKGROUND

Few studies have evaluated the administration of intravenous (IV) insulin infusions for uncontrolled hyperglycemia in non-intensive care unit (ICU) patients, and there is inadequate data to guide how to appropriately administer IV insulin infusions to this patient population.

OBJECTIVE

Determine the effectiveness and safety of our institution's non-critical care IV insulin infusion order set.

METHODS

This retrospective study was conducted at 2 institutions within a health care system. The primary outcome was the number of individuals who achieved a glucose level ≤180 mg/dL. For those meeting this endpoint, the time to achieving this outcome and the percentage of glucose checks within the goal range were determined. The primary safety endpoint was the number of individuals who experienced hypoglycemia (glucose level <70 mg/dL). Patients were included if they were ≥18 years of age and received the non-critical care IV insulin infusion order set outside of the ICU.

RESULTS

Twenty-one (84%) patients achieved a glucose level ≤180 mg/dL. The median (inter-quartile range [IQR]) time to achieving the primary outcome was 5.7 h (3.9-8.3). In patients who achieved the primary outcome, 41.8% of the glucose readings obtained after achieving this outcome were within goal range. Two (8%) patients experienced hypoglycemia. Both of these events occurred within 8 hours of therapy initiation and neither patient received prior doses of subcutaneous insulin. Of the 4 patients who did not achieve a glucose level ≤180 mg/dL, 2 received high-dose corticosteroids, and 3 achieved a glucose level between 181 and 200 mg/dL.

CONCLUSION AND RELEVANCE

Our findings support the safe administration of IV insulin infusions to non-ICU patients when targeting a glucose range of 140 to 180 mg/dL and limiting the infusion duration.

Cost-effectiveness of canagliflozin and dapagliflozin for treatment of patients with chronic kidney disease and type 2 diabetes

AIM

To examine the cost-effectiveness of adding canagliflozin or dapagliflozin to standard of care (SoC) versus SoC alone in patients with chronic kidney disease (CKD) and type 2 diabetes (T2D).

MATERIALS AND METHODS

We used a Markov microsimulation model to assess the cost-effectiveness of canagliflozin plus SoC (canagliflozin + SoC), dapagliflozin plus SoC (dapagliflozin + SoC) and SoC alone. Analyses were conducted from a healthcare system perspective. Costs were measured in 2021 Canadian dollars (C$), and effectiveness was measured in quality-adjusted life-years (QALYs).

RESULTS

Over a patient's lifetime, canagliflozin + SoC and dapagliflozin + SoC yielded cost savings of C$33 460 and C$26 764 and generated 1.38 and 1.44 additional QALYs compared with SoC alone, respectively. While QALY gains with dapagliflozin + SoC were higher than those with canagliflozin + SoC, this strategy was also more costly with the incremental cost-effectiveness ratio exceeding the willingness to pay threshold of C$50 000 per QALY. Dapagliflozin + SoC, however, generated cost savings and QALY gains compared with canagliflozin + SoC over shorter time horizons of 5 or 10 years.

CONCLUSIONS

Dapagliflozin + SoC was not cost-effective versus canagliflozin + SoC in patients with CKD and T2D over the lifetime horizon. However, adding canagliflozin or dapagliflozin to SoC was less costly and more effective relative to SoC alone for treatment of CKD and T2D.

The SQuID protocol (subcutaneous insulin in diabetic ketoacidosis): Impacts on ED operational metrics

BACKGROUND

Studies using fast-acting subcutaneous (SQ) insulin analogs in diabetic ketoacidosis (DKA) have demonstrated efficacy, safety, and cost-effectiveness, allowing treatment of mild-to-moderate (MTM)-severity DKA patients in non-intensive care unit (ICU) settings. However, emergency department (ED)-based studies are few, with limited exploration of impacts on operational metrics.

METHODS

We implemented the SQuID (Subcutaneous Insulin in Diabetic Ketoacidosis) protocol for adults with MTM-severity DKA in an urban academic ED, collecting data from August 1, 2021, to February 28, 2022. We examined fidelity (frequency of required q2h glucose checks), safety (proportion of patients administered rescue dextrose for hypoglycemia), and ED length of stay (EDLOS) for the SQuID cohort compared to patients (non-ICU) treated with a traditional insulin infusion. We also examined ICU admission rate among MTM-severity DKA patients after introduction of SQuID to two historical control periods (pre-intervention and pre-COVID). We used Mann-Whitney U to test for differences in EDLOS distributions, bootstrapped (n = 1000) confidence intervals (CIs) for EDLOS median differences, and the two-sample z-test for differences in ICU admissions.

RESULTS

We identified 177 MTM-severity DKA patients in the study period (78 SQuID, 99 traditional cohort) and 163 preintervention and 161 pre-COVID historical control patients. Fidelity to the SQuID pathway was good, with glucose checks exceeding the q2-h requirement. We found no difference in the proportion of rescue dextrose administration compared to the traditional pathway. We observed significant reductions in median EDLOS for the SQuID cohort compared to the traditional cohort during the study period (-3.0, 95% CI -8.5 to -1.4), the preintervention period (-1.4, 95% CI -3.1 to -0.1), and the pre-COVID control period (-3.6, 95% CI -7.5 to -1.8).

CONCLUSIONS

In this single-center study at an academic ED, treatment of patients with MTM-severity DKA with a SQ insulin protocol was effective, demonstrated equivalent safety, and reduced ED length of stay.

Cost analysis of hospitals performing continuous albuterol in non-intensive care settings

OBJECTIVE

To compare hospital costs and resource utilization for pediatric asthma admissions based on the hospitals' availability of continuous albuterol aerosolization administration (CAA) in non-intensive care unit (ICU) settings.

METHODS

We conducted a retrospective cohort study of children ages 2-17 years admitted in 2019 with a principal diagnosis of asthma using the Pediatric Health Information System. Hospitals and hospitalizations were categorized based on location of CAA administration, ICU-only versus general inpatient floors. Hospitals preforming CAA in an intermediate care unit were excluded. We calculated total cost, standardized unit costs and rates of interventions. Groups were compared using Chi-Square, t-test and Wilcoxon rank-sum test as indicated. A log linear mixed model was created to evaluate potential confounders.

RESULTS

Twenty-one hospitals (7084 hospitalizations) allowed CAA on the floor.Twenty-four hospitals (6100 hospitalizations) allowed CAA in the ICU-only. Median total cost was $4639 (Interquartile Range (IQR) $3060-$7512) for the floor group and $5478 (IQR $3444-$8539) for the ICU-only group (p < 0.001) (mean cost difference of $775 per patient). Hospitalization costs were $4,726,829 (95% CI $3,459,920-$5,993,860) greater for the children treated at hospitals restricting CAA to the ICU. We observed higher standardized laboratory, imaging, clinical and other unit costs, along with higher use of interventions in the ICU-only group. After adjustment, we found that ICU stay and hospital LOS were the main drivers of cost difference between the groups.

CONCLUSIONS

There was cost savings and decreased resource utilization for hospitals that performed CAA on the floor. Further studies exploring variations in asthma management are warranted.

Hospitalizations for ketoacidosis in type 1 diabetes mellitus, 2008 to 2018

The objective of this study was to characterize epidemiological trends, outcomes in hospitalized patients, and the disease burden of hospitalizations for diabetic ketoacidosis (DKA) in patients with type 1 diabetes mellitus (T1DM). This was a retrospective interrupted trends study involving hospitalizations for DKA in patients with T1DM in the US from 2008 to 2018 using data from the Nationwide Inpatient Sample. The total number of hospitalizations during each calendar year was obtained, and trends in inpatient mortality rate, mean length of hospital stay (LOS), and mean total hospital cost (THC) were calculated. Between 2008 and 2018, there was a trend toward increasing hospitalizations for T1DM with DKA (P-trend <0.001). Over the decade, there was a steady rise in the proportion of patients with a Charlson comorbidity index >1. There was no statistically significant change in adjusted inpatient mortality in patients with T1DM admitted for DKA over the study period despite an apparent trend of a decreasing crude mortality rate (P-trend = 0.063). There was a statistically significant decrease in both LOS and THC over the study period. In conclusion, there was a significant decrease in both LOS and THC, potentially reflecting improvements in the management of DKA in patients with T1DM.

Predictors and outcomes of recurrent diabetic ketoacidosis in Israeli adults

AIMS

To identify risk factors for recurrent episodes of DKA that may allow the development of an effective prevention strategies.

METHODS

Retrospective analysis of admissions for DKA in adult patients between 2004, and 2017 in a tertiary hospital. The clinical characteristics and outcomes of DKA of patients were stratified into an isolated episode of DKA (group 1) and recurrent episodes (group 2).

RESULTS

385 patients were included in the study, 281 had a single admission of DKA, and 104 had recurrent admissions. There were no statistically significant differences between the two groups in demographic or clinical variables. Patients in the recurrent DKA group had a younger age at diabetes diagnosis, 32.1 ± 17.08 vs. 36.13 ± 19.52 (p = 0.05). Patients with A1C greater than 9.0% were associated with recurrent DKA in cox regression analysis (HR 2.023; 95% Cl 1.112-3.679; p = 0.021). Recurrent DKA was a significant predictor of one-year mortality in cox regression analysis (HR 0.172; 95% CI 0.04-0.742; p = 0.018).

CONCLUSION

High A1C levels, which account for poorly controlled diabetes, was identified as the strongest predictor of recurrent DKA. This patient population warrants particular attention and the development of intervention strategies in further studies.

Risk factors and prevention strategies for diabetic ketoacidosis in people with established type 1 diabetes

Diabetic ketoacidosis (DKA) is a serious acute complication of type 1 diabetes, which is receiving more attention given the increased DKA risk associated with SGLT inhibitors. Sociodemographic and modifiable risk factors were identified with strong evidence for an increased risk of DKA, including socioeconomic disadvantage, adolescent age (13-25 years), female sex, high HbA_1c, previous DKA, and psychiatric comorbidities (eg, eating disorders and depression). Possible prevention strategies, which include the identification of people at risk based on non-modifiable sociodemographic risk factors, are proposed. As a second risk mitigation strategy, structured diabetes self-management education that addresses modifiable risk factors can be used. Evidence has found that structured education leads to reduced DKA rates. Knowledge of these risk factors and potent risk mitigation strategies are important to identify subgroups of people with an elevated DKA risk. This knowledge should also be used when adjunct therapy options with an increased DKA risk are considered. Prevention of DKA in people with type 1 diabetes is an important clinical task, which should also be addressed when SGLT inhibitors are part of therapy.

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.

Improving Disposition Decision-Making for Pediatric Diabetic Ketoacidosis: A Quality Improvement Study

Introduction:

In many centers, children with diabetic ketoacidosis (DKA) receive care either in an endocrinology ward or a pediatric intensive care unit (PICU). We conducted a quality improvement (QI) initiative to reduce potentially avoidable PICU admissions of children with DKA without increasing endocrinology ward-to-PICU transfers.

Methods:

A survey of providers demonstrated opportunities to increase awareness of institutional criteria for PICU admissions of children with DKA. We created an electronic health record (EHR) dot-phrase, prepopulated with these criteria, and placed a note in the EHR for all patients with DKA as a reference for all providers. An EHR-based data report was created to monitor the disposition of DKA patients and the use of the dot-phrase (process measure). The primary outcome measure was the potentially avoidable PICU admissions for patients with DKA. Endocrinology ward-to-PICU transfers were tracked as a balancing measure to ensure safe disposition.

Results:

After the implementation of the dot-phrase, use was variable, but averaged 33.4% over 1 year. The percentage of DKA admissions classified as potentially avoidable PICU stays decreased from 4.1% to 0.5%, with a concurrent decrease in the total percentage of PICU admissions for DKA from 19.1% to 8.4%. The percentage of endocrinology ward-to-PICU transfers also declined from 0.8% to 0%.

Conclusions:

A novel EHR-based intervention increasing awareness and documentation of established pediatric DKA management guidelines can be used to safely reduce PICU admissions for DKA without increasing the rate of endocrinology ward-to-intensive care unit transfers.

Clinical characteristics and outcomes of care in adult patients with diabetic ketoacidosis: A retrospective study from a tertiary diabetes center in Thailand

Background

Diabetic ketoacidosis (DKA) is a metabolic catastrophe which could occur in any type of diabetes. Even when fundamental key points of DKA treatment had been followed, some differences exist in treatment protocols in each physician, highlighting the need to assess adherence to DKA guideline.

Aim

This study aimed to examine trend of hospitalized DKA patients and outcomes of treatment over a decade at Theptarin Hospital, a multi-discipline based diabetes center in Thailand.

Method

A retrospective study of DKA episodes admitted over a 14-year period (2005–2018) was done. Clinical characteristics, laboratory data, type of diabetes, severity of DKA were collected and analyzed.

Results

A total of 94 DKA episodes occurred in 81 diabetic patients (females 61.5%, mean age 47.4 ± 20.4 years, T1DM 41.5%, T2DM 50.0%, Ketosis-prone diabetes 8.5%, baseline A1C 10.8 ± 3.0%). While infection was the common precipitating factor in T2DM, omission of insulin was the usual precipitating factor in T1DM. During ongoing management, 26.6% of patients developed hypokalemia and supplementation was not prescribed as per protocol in this group of patients. Almost 13% of patients experienced hypoglycemia in the first 24 h. Median time to resolution of DKA was 8.5 h. Four T2DM patients expired from the precipitating cause of DKA which accounted for mortality rate at 4.3% in our study.

Conclusions

Inadequate metabolic monitoring and iatrogenic hypoglycemia remain areas of concern for DKA management. Occurrence of hypokalemia was related to poor adherence to protocol guidance on potassium supplementation. A strengthened educational program for nursing and medical staffs should be emphasized.