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Abulebda K, Whitfill T, Montgomery EE, Kirby ML, Ahmed RA, Cooper DD, Nitu ME, Auerbach MA, Lutfi R, Abu-Sultaneh S. Improving Pediatric Diabetic Ketoacidosis Management in Community Emergency Departments Using a Simulation-Based Collaborative Improvement Program. Pediatr Emerg Care 2021; 37:543-549. [PMID: 30870337 DOI: 10.1097/pec.0000000000001751] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The majority of pediatric patients with diabetic ketoacidosis (DKA) present to community emergency departments (CEDs) that are less prepared to care for acutely ill children owing to low pediatric volume and limited pediatric resources and guidelines. This has impacted the quality of care provided to pediatric patients in CEDs. We hypothesized that a simulation-based collaborative program would improve the quality of the care provided to simulated pediatric DKA patients presenting to CEDs. METHODS This prospective interventional study measured adherence of multiprofessional teams caring for pediatric DKA patients preimplementation and postimplementation of an improvement program in simulated setting. The program consisted of (a) a postsimulation debriefing, (b) assessment reports, (c) distribution of educational materials and access to pediatric resources, and (d) ongoing communication with the academic medical center (AMC). All simulations were conducted in situ (in the CED resuscitation bay) and were facilitated by a collaborative team from the AMC. A composite adherence score was calculated using a critical action checklist. A mixed linear regression model was performed to examine the impact of CED and team-level variables on the scores. RESULTS A total of 91 teams from 13 CEDs participated in simulated sessions. There was a 22-point improvement of overall adherence to the DKA checklist from the preintervention to the postintervention simulations. Six of 9 critical checklist actions showed statistically significant improvement. Community emergency departments with medium pediatric volume showed the most overall improvement. Teams from CEDs that are further from the AMC showed the least improvement from baseline. CONCLUSIONS This study demonstrated a significant improvement in adherence to pediatric DKA guidelines in CEDs across the state after execution of an in situ simulation-based collaborative improvement program.
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Affiliation(s)
- Kamal Abulebda
- From the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indiana University Health, Indianapolis, IN
| | | | | | | | - Rami A Ahmed
- Department of Emergency Medicine, Indiana University School of Medicine, Indiana University Health, Indianapolis, IN
| | - Dylan D Cooper
- Department of Emergency Medicine, Indiana University School of Medicine, Indiana University Health, Indianapolis, IN
| | - Mara E Nitu
- From the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indiana University Health, Indianapolis, IN
| | | | - Riad Lutfi
- From the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indiana University Health, Indianapolis, IN
| | - Samer Abu-Sultaneh
- From the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indiana University Health, Indianapolis, IN
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Thawer Z, Gregoire K, Coo H, Saleh DS. Variability in Emergency Management of Pediatric Diabetic Ketoacidosis. Can J Diabetes 2021; 45:757-760. [PMID: 34112617 DOI: 10.1016/j.jcjd.2021.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 02/27/2021] [Accepted: 03/09/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Our aim in this study was to identify pediatric patients presenting in diabetic ketoacidosis (DKA) who received initial treatment inconsistent with current guidelines, and then to track associated complications. METHODS This retrospective chart review examined 47 pediatric patients admitted to our institution with DKA, including those transferred from community hospitals. Primary outcome measures were exposure to treatment-related risk factors for cerebral edema (CE), including administration of an intravenous (IV) insulin bolus, IV bicarbonate, insulin within 1 hour of IV fluid start and non-NPO (nil per os) status. RESULTS Seventy-five percent of patients were exposed to at least one management practice that deviated from guidelines. Thirty-four percent of patients were exposed to a treatment-related risk factor for CE, with a significantly higher prevalence in those presenting to community centres (52% vs 19%; p=0.02). There were no radiologically confirmed cases of CE. CONCLUSIONS Despite the presence of multiple, evidence-based guidelines, a significant proportion of children---and especially those who present to community centres---are exposed to practices that increase CE risk.
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Affiliation(s)
- Zoyah Thawer
- Department of Pediatrics, Queen's University, Kingston, Ontario, Canada; Division of Pediatric Endocrinology and Metabolism, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada.
| | - Keith Gregoire
- Department of Pediatrics, Queen's University, Kingston, Ontario, Canada
| | - Helen Coo
- Department of Pediatrics, Queen's University, Kingston, Ontario, Canada
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3
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Malcolm J, Halperin I, Moore S, Houlden RL. Variability of Clinical Practice Management of Type 1 and Type 2 Diabetes During Surgery Across Canada. Can J Diabetes 2020; 45:519-523.e2. [PMID: 33358540 DOI: 10.1016/j.jcjd.2020.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 10/19/2020] [Accepted: 10/23/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE As part of a larger project to develop quality standards in perioperative diabetes management, the goal of this project was to assess self-reported management of surgical patients with diabetes across healthcare institutions and specialties in Canada. METHODS Current practice of perioperative management of patients with diabetes was assessed using multiple-choice questions based on commonly encountered clinical scenarios involving patients with type 1 and type 2 diabetes. The survey was sent to a broad stakeholder group of individuals involved in perioperative medicine in academic and community settings across Canada. RESULTS Responses to clinical case scenarios demonstrated more consistent approaches for patients with type 1 diabetes undergoing cardiac surgery, possibly reflecting more robust evidence. There was more variability in the management of noninsulin antihyperglycemic agents and hyperglycemia in patients with type 2 diabetes undergoing noncardiac surgery. CONCLUSIONS Given the variability in clinical practice, standards and clinical tools are required for perioperative and periprocedural glycemic management in Canada to inform practice, improve the experience and outcomes for people with diabetes and provide a foundation for quality improvement initiatives and benchmarking.
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Affiliation(s)
- Janine Malcolm
- Division of Endocrinology and Metabolism, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
| | - Ilana Halperin
- Division of Endocrinology, University of Toronto, Toronto, Ontario, Canada
| | - Sarah Moore
- School of Nursing (PhD candidate), Queen's University, Kingston, Ontario, Canada
| | - Robyn L Houlden
- Division of Endocrinology, Queen's University, Kingston, Ontario, Canada
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Bhatt P, Dave M, Amponsah JK, Jain A, Yagnik P, Asare-Afriyie B, Donda K, Sharma M, Parmar N, Patel A, Bhatt N, Lunsford AJ, Dapaah-Siakwan F. Etiologies, trends, and predictors of 30-day pediatric readmissions after hospitalizations for diabetic ketoacidosis in the United States. Pediatr Diabetes 2020; 21:969-978. [PMID: 32469429 DOI: 10.1111/pedi.13059] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 05/22/2020] [Accepted: 05/23/2020] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To determine the causes, predictors, and trends of 30-day readmissions following hospitalizations for pediatric diabetic ketoacidosis (DKA) in the United States (US) from 2010 to 2014. RESEARCH DESIGN AND METHODS We used International Classification of Diseases, ninth revision, Clinical Modification codes to identify children with DKA aged 2 to 18 years from the National Readmission Database in the US. Patients who had readmission within 30 days after an index admission for DKA were included in the study. We combined similar diagnoses into clinically important categories to determine the cause of readmission. The primary outcome was all-cause 30-day (AC30) readmissions. Categorical and continuous variables were analyzed using chi-square or student's t-test or Wilcoxon rank sum tests respectively. We performed multivariable logistic regression to identify predictors of 30-day readmission. RESULTS From 2010 through 2014, a weighted total of 87 815 index DKA-related pediatric hospitalizations were identified of which, 4055 patients (4.6%) had AC30 readmissions and this remained unchanged during the study period. Of all the readmissions, 69% were attributed to DKA. In multivariable regression analysis, the odds of AC30 readmission and 30-day readmission attributed to DKA alone were increased for females, adolescents, patients with depression and psychosis, and discharge against medical advice, while private insurance, the highest income quartile, and admission at teaching hospitals were associated with lower odds of AC30 readmission and 30-day readmission attributed to DKA only. CONCLUSION We identified several factors associated with readmission after hospitalization for DKA. Addressing these factors such as depression may help lower readmissions after an admission for DKA.
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Affiliation(s)
- Parth Bhatt
- Department of Pediatrics, United Hospital Center, Bridgeport, West Virginia
| | - Mihir Dave
- Department of Internal Medicine, University of Nevada, Reno, Nevada
| | - Jason K Amponsah
- Department of Public Health, Emory School of Public Health, Atlanta, Georgia
| | - Apurva Jain
- Department of Pediatrics, Texas Tech University Health Sciences Center, Amarillo, Texas
| | - Priyank Yagnik
- Department of Pediatrics, University of Kansas School of Medicine, Wichita, Kansas
| | - Barbara Asare-Afriyie
- Department of Public Health, Tulane School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Keyur Donda
- Department of Pediatrics, University South Florida, Tampa, Florida
| | - Mayank Sharma
- Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida
| | - Narendrasinh Parmar
- Department of Pediatrics, Brookdale University Hospital Medical Center, Brooklyn, New York
| | - Achint Patel
- Department of Internal Medicine, University of Nevada, Reno, Nevada
| | - Neel Bhatt
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Alison J Lunsford
- Department of Pediatrics, Texas Tech University Health Sciences Center, Amarillo, Texas
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McGee RG, Cowell CT, Arnolda G, Ting HP, Hibbert P, Dowton SB, Braithwaite J. Assessing guideline adherence in the management of type 1 diabetes mellitus in Australian children: a population-based sample survey. BMJ Open Diabetes Res Care 2020; 8:8/1/e001141. [PMID: 32709758 PMCID: PMC7380831 DOI: 10.1136/bmjdrc-2019-001141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 05/12/2020] [Accepted: 05/24/2020] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION To estimate adherence to clinical practice guidelines in selected settings at a population level for Australian children with type 1 diabetes mellitus. RESEARCH DESIGN AND METHODS Medical records of children with type 1 diabetes mellitus aged 0-15 years in 2012-2013 were targeted for sampling across inpatient, emergency department and community visits with specialist pediatricians in regional and metropolitan areas and tertiary pediatric hospitals in three states where approximately 60% of Australian children reside. Clinical recommendations extracted from two clinical practice guidelines were used to audit adherence. Results were aggregated across types of care (diagnosis, routine care, emergency care). RESULTS Surveyors conducted 6346 indicator assessments from an audit of 539 healthcare visits by 251 children. Average adherence across all indicators was estimated at 79.9% (95% CI 69.5 to 88.0). Children with type 1 diabetes mellitus have higher rates of behavioral and psychological disorders, but only a third of children (37.9%; 95% CI 11.7 to 70.7) with suboptimal glycemic control (eg, hemoglobin A1c >10% or 86 mmol/mol) were screened for psychological disorders using a validated tool; this was the only indicator with <50% estimated adherence. Adherence by care type was: 86.1% for diagnosis (95% CI 76.7 to 92.7); 78.8% for routine care (95% CI 65.4 to 88.9) and 83.9% for emergency care (95% CI 78.4 to 88.5). CONCLUSIONS Most indicators for care of children with type 1 diabetes mellitus were adhered to. However, there remains room to improve adherence to guidelines for optimization of practice consistency and minimization of future disease burden.
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Affiliation(s)
- Richard G McGee
- Central Coast Clinical School, The University of Newcastle Faculty of Health and Medicine, Callaghan, New South Wales, Australia
| | - Chris T Cowell
- The University of Sydney Children's Hospital Westmead Clinical School, Sydney, New South Wales, Australia
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Gaston Arnolda
- Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, New South Wales, Australia
| | - Hsuen P Ting
- Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, New South Wales, Australia
| | - Peter Hibbert
- Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, New South Wales, Australia
- Australian Centre for Precision Health, University of South Australia Cancer Research Institute (UniSA CRI), School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - S Bruce Dowton
- Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, New South Wales, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, New South Wales, Australia
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Amer YS, Al Nemri A, Osman ME, Saeed E, Assiri AM, Mohamed S. Perception, attitude, and satisfaction of paediatric physicians and nurses towards clinical practice guidelines at a university teaching hospital. J Eval Clin Pract 2019; 25:543-549. [PMID: 29611621 DOI: 10.1111/jep.12923] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 02/27/2018] [Accepted: 03/02/2018] [Indexed: 01/09/2023]
Abstract
RATIONALE, AIMS, AND OBJECTIVES To explore perception, attitude, and satisfaction of paediatric clinicians, trainees, and nurses at King Khalid University Hospital towards clinical practice guidelines (CPGs) including the locally adapted diabetic ketoacidosis CPG (DKA-CPG). METHODS A cross-sectional survey was distributed to 260 doctors and nurses working in the paediatrics department. RESULTS The response rate was 95.4%. The respondents had a positive perception and attitude towards general CPGs and specifically for the DKA-CPG; 98.7% thought CPGs were useful sources of advice, improved safety, and decreased risk, and reduced variation in practice. A total of 99.2% thought CPGs were good clinical tools, 98.3% satisfied with, had confidence in well-developed CPGs, and would recommend them to their colleagues to use, and 94.6% agreed they were cost-effective. The preferred format for CPGs was paper (46.6%) and electronic (42.9%). The DKA-CPG helped in managing patients and respondents were all satisfied and had confidence with it (100%). The rationale and objectives of the DKA-CPG were clear for 99.25%; 98.5% thought the layout was clear and well organized and user-friendly (96.2%). Compared with nurses, physicians had a higher perception towards CPGs in general (P < .05) and the DKA-CPG (P < .05). CONCLUSIONS The paediatric doctors, and nurses have a great perception and satisfaction and positive attitude towards CPGs in general, towards the paediatric diabetic ketoacidosis CPG in particular, which in turn had a positive impact on the acceptability and implementation of the CPGs. These findings could help in sustaining a safe and high-quality health care environment through implementation of evidence-based CPGs.
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Affiliation(s)
- Yasser Sami Amer
- Quality Management Department, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia.,Research Chair for Evidence-Based Health Care and Knowledge Translation, Deanship of Scientific Research, King Saud University, Riyadh, Saudi Arabia.,Alexandria Centre for Evidence-Based Clinical Practice Guidelines, Alexandria University Medical Council, Alexandria University, Alexandria, Egypt
| | - Abdulrahman Al Nemri
- Department of Paediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mohamed Elfaki Osman
- Department of Paediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Elshazaly Saeed
- Prince Abdullah Bin Khalid Celiac Disease Research Chair, Deanship of Scientific Research, King Saud University, Riyadh, Saudi Arabia
| | - Asaad Mohamed Assiri
- Department of Paediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Prince Abdullah Bin Khalid Celiac Disease Research Chair, Deanship of Scientific Research, King Saud University, Riyadh, Saudi Arabia
| | - Sarar Mohamed
- Department of Paediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Prince Abdullah Bin Khalid Celiac Disease Research Chair, Deanship of Scientific Research, King Saud University, Riyadh, Saudi Arabia.,Department of Paediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
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Treadgold R, Boon D, Squires P, Courtman S, Endacott R. Implementation of paediatric pain care-bundle across South-West England clinical network of Emergency Departments and Minor Injury Units: A before and after study. Int Emerg Nurs 2018; 43:56-60. [PMID: 30381143 DOI: 10.1016/j.ienj.2018.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 08/15/2018] [Accepted: 10/07/2018] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Pain management in children is often poorly executed in Emergency Departments and Minor Injury Units. The aim of this study was to assess the impact of a care bundle comprising targeted education on pain score documentation and provision of appropriately dosed analgesia for the paediatric population attending Emergency Departments (EDs) and Minor Injury Units (MIUs). METHODS A total of 29 centres - 5 EDs and 24 MIUs - participated in an intervention study initiated by Emergency Nurse Practitioners to improve paediatric pain management. In Phase 1, up to 50 consecutive records of children under 18 presenting at each MIU and ED were examined (n = 1201 records); Pain Score (PS), age, whether the child was weighed, and provision of analgesia was recorded. A care bundle consisting of an education programme, paediatric dosage chart and flyers, was then introduced across the 29 centres. Nine months following introduction of the care bundle, the same data set was collected from units (Phase 2, n = 1090 records). RESULTS The likelihood of children having a pain score documented increased significantly in Phase 2 (OR 6.90, 95% CI 5.72-8.32), The likelihood of children receiving analgesia also increased (OR1.82, 95% CI 1.51-2.19), although there was no increase in the proportion of children with moderate or severe pain receiving analgesia. More children were weighed following the care bundle (OR 2.58 95% CI 1.86-3.57). Infants and children who were not weighed were more likely to receive an incorrect analgesia dose (p < 0.01). CONCLUSIONS Rates of PS documentation improved and there was greater provision of analgesia overall following introduction of the care bundle. Although weighing of children did improve, the levels remain disappointingly low. EDs generally performed better than MIUs. The results show there were some improvements with this care bundle, but future work is needed to determine why pain management continues to fall below expected standards and how to further improve and sustain the impact of the care bundle.
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Affiliation(s)
- Ruth Treadgold
- Anaesthetic Department, Plymouth Hospitals NHS Trust, Plymouth PL6 8DH, UK.
| | - Daranee Boon
- Emergency Department, Derriford Hospital, Plymouth PL6 8DH, UK.
| | - Phillipa Squires
- Anaesthetic Department, Torbay and South Devon NHS Foundation Trust, Torquay TQ2 7AA, UK.
| | - Simon Courtman
- Anaesthetic Department, Derriford Hospital, Plymouth PL6 8DH, UK.
| | - Ruth Endacott
- Plymouth University/Royal Devon and Exeter Hospital Clinical School, Faculty of Health and Human Sciences, Plymouth University, Plymouth PL4 8AA, UK; School of Nursing and Midwifery, Monash University, Melbourne, VIC 3199, Australia.
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Ronsley R, Islam N, Ronsley C, Metzger DL, Panagiotopoulos C. Adherence to a pediatric diabetic ketoacidosis protocol in children presenting to a tertiary care hospital. Pediatr Diabetes 2018; 19:333-338. [PMID: 28664545 DOI: 10.1111/pedi.12556] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 05/24/2017] [Accepted: 06/06/2017] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To review adherence to a provincial diabetic ketoacidosis (DKA) protocol and to assess factors associated with intravenous fluid administration and the length time on an insulin infusion. METHODS A retrospective chart review was conducted of all DKA admissions to British Columbia Children's Hospital (BCCH) during September 2008 to December 2013. Data collection included diabetes history, estimation of dehydration, insulin and fluid infusion rates, and frequency of laboratory investigations. Markers of adherence included appropriate use of a fluid bolus, normal saline and insulin infusion time, fluid intake and outputs, and the frequency of blood work during the insulin infusion. A log-linear regression model was fitted to assess the factors associated with insulin infusion duration. RESULTS Of 157 children (median [interquartile range] age: 10.6 years [5.0, 13.8]) hospitalized for DKA, 45% (n = 70) were male, 55% (n = 86) were transferred from other hospitals, and 26% (n = 40) were admitted to intensive care unit. Thirty-five percent of subjects estimated to have mild or moderate dehydration received fluid boluses. In the adjusted analysis, the average duration on DKA protocol was 39% (95% confidence interval [CI]: 12%, 67%) longer for children admitted with severe dehydration (compared to those with mild dehydration). CONCLUSIONS Health care providers' adherence to the BCCH DKA protocol is poor. More severe dehydration at presentation is associated with longer duration of insulin infusion. Further knowledge translation initiatives focused on accurate estimation of volume depletion to ensure appropriate initial fluid resuscitation-as well as careful monitoring during DKA hospitalization-are important, especially in community centers.
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Affiliation(s)
- Rebecca Ronsley
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Nazrul Islam
- School of Population and Public Health, University of British Columbia, Vancouver, Canada.,Harvard T. H. Chan School of Public Health, Harvard University, Boston, USA
| | - Claire Ronsley
- Endocrinology and Diabetes Unit, BC Children's Hospital, Vancouver, Canada
| | - Daniel L Metzger
- Department of Pediatrics, University of British Columbia, Vancouver, Canada.,Endocrinology and Diabetes Unit, BC Children's Hospital, Vancouver, Canada
| | - Constadina Panagiotopoulos
- Department of Pediatrics, University of British Columbia, Vancouver, Canada.,Endocrinology and Diabetes Unit, BC Children's Hospital, Vancouver, Canada
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von Oettingen JE, Rhodes ET, Wolfsdorf JI. Resolution of ketoacidosis in children with new onset diabetes: Evaluation of various definitions. Diabetes Res Clin Pract 2018; 135:76-84. [PMID: 29111277 PMCID: PMC6013285 DOI: 10.1016/j.diabres.2017.09.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 08/22/2017] [Accepted: 09/18/2017] [Indexed: 01/21/2023]
Abstract
AIMS Data are sparse concerning use of serum electrolyte parameters as compared to venous blood gas (VBG) measurements to monitor acid-base status during treatment of diabetic ketoacidosis (DKA). We explored the utility of various parameters to define DKA resolution by investigating the relationship of venous pH (vpH), anion gap (AG), serum bicarbonate (HCO3), and glucose concentration during management of DKA in children with new onset diabetes mellitus (NODM). METHODS We included all patients with NODM presenting with DKA to Boston Children's Hospital from 10/1/07-7/1/13. DKA was defined as serum glucose ≥ 200 mg/dL (11.1 mmol/L) and vpH<7.30; severity as mild <7.30, moderate<7.20, severe<7.10; resolution of DKA as vpH≥7.30 and AG≤18 mmol/L. We used Cox regression to determine time to DKA resolution, and logistic regression to evaluate different serum HCO3 cut-off values as predictors of DKA resolution. RESULTS 263 patients (133F, mean age 9.9±4.4 years, 74% White) were included. DKA was mild in 134 (51%), moderate in 75 (28%) and severe in 54 (20%). In mild DKA, AG closed after normalization of vpH; in moderate and severe DKA, AG closed before normalization of vpH. HCO3>15mmol/L correlated with vpH≥7.30, and had 76% sensitivity and 85% specificity to predict DKA resolution. Median times to DKA resolution were similar using two different definitions: vpH and AG (8.4h [IQR 6.3-11.9]) vs. HCO3>15 mmol/L (7.9 h [IQR 5.0-11.8]), p=.42. CONCLUSIONS During management of pediatric DKA, HCO3 > 15 mmol/L reliably predicts resolution of DKA. In low-resource settings where VBG is unavailable, electrolyte parameters alone may be used to determine DKA resolution.
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Affiliation(s)
- Julia E von Oettingen
- Division of Endocrinology, Montreal Children's Hospital, McGill University Health Center, Montreal, QC H4A3J1, Canada; Division of Endocrinology, Boston Children's Hospital, Boston, MA 02115, USA.
| | - Erinn T Rhodes
- Division of Endocrinology, Boston Children's Hospital, Boston, MA 02115, USA; Harvard Medical School, Boston, MA 02115, USA
| | - Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, MA 02115, USA; Harvard Medical School, Boston, MA 02115, USA
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10
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Cohen M, Leibovitz N, Shilo S, Zuckerman-Levin N, Shavit I, Shehadeh N. Subcutaneous regular insulin for the treatment of diabetic ketoacidosis in children. Pediatr Diabetes 2017; 18:290-296. [PMID: 27005007 DOI: 10.1111/pedi.12380] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Revised: 02/19/2016] [Accepted: 02/24/2016] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) treatment protocols vary, however low-dose intravenous administration of regular insulin is the standard care for replacing insulin in most centers. Few studies, the majority in adults, demonstrated subcutaneous injection of rapid-acting insulin every 1-2 hours to be a valid alternative. OBJECTIVE To evaluate the efficacy and safety of subcutaneous regular insulin administered every 4 hours in pediatric DKA in a clinical setting. METHODS A retrospective chart review was conducted. Charts of all children treated with subcutaneous regular insulin for DKA and pH ≥ 7.0, between 2007 and 2010, were reviewed. Seventy-six DKA episodes in 52 patients were included. Data regarding clinical characteristics, response to treatment, and the occurrence of complications were analyzed. DKA episodes in patients with new-onset diabetes and in those with established diabetes were compared. RESULTS Mean age was 11.6 ± 4.0 yr. Eighteen episodes occurred in children with new-onset diabetes. In all episodes, our protocol resulted in recovery from DKA. Median time to DKA resolution (pH > 7.30, HCO3 > 15) was 10.3 (5.5, 14.2) h. The median total insulin dose was 0.05 (0.04, 0.06) (unit/kg/h). During DKA treatment, hypoglycemia occurred in one episode and hypokalemia, mostly mild, was documented in 14. No cardiac arrhythmias, incidents of cerebral edema, or mortality occurred. CONCLUSION Subcutaneous regular insulin administered every 4 hours is an effective and safe alternative for the insulin treatment of DKA with pH > 7.0 in children. Such treatment has the potential to simplify insulin administration when compared to either intravenous regular insulin or q1-2 hour subcutaneous rapid insulin and reduce both patient inconvenience and admission costs.
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Affiliation(s)
- Michal Cohen
- Pediatric Diabetes unit and Pediatrics A Division, Ruth Rappaport Children's Hospital of Haifa, Rambam Healthcare Campus, Haifa, Israel
| | - Noa Leibovitz
- Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Smadar Shilo
- Pediatric Diabetes unit and Pediatrics A Division, Ruth Rappaport Children's Hospital of Haifa, Rambam Healthcare Campus, Haifa, Israel
| | - Nehama Zuckerman-Levin
- Pediatric Diabetes unit and Pediatrics A Division, Ruth Rappaport Children's Hospital of Haifa, Rambam Healthcare Campus, Haifa, Israel.,Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Itai Shavit
- Pediatric Diabetes unit and Pediatrics A Division, Ruth Rappaport Children's Hospital of Haifa, Rambam Healthcare Campus, Haifa, Israel.,Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Naim Shehadeh
- Pediatric Diabetes unit and Pediatrics A Division, Ruth Rappaport Children's Hospital of Haifa, Rambam Healthcare Campus, Haifa, Israel.,Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
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Zee-Cheng JE, Webber EC, Abu-Sultaneh S. Adherence to pediatric diabetic ketoacidosis guidelines by community emergency departments' providers. Int J Emerg Med 2017; 10:11. [PMID: 28321786 PMCID: PMC5359190 DOI: 10.1186/s12245-017-0137-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 03/14/2017] [Indexed: 02/01/2023] Open
Abstract
Background Diabetic ketoacidosis (DKA) is a common presentation of type I diabetes mellitus to the emergency departments. Most children with DKA are initially managed in community emergency departments where providers may not have easy access to educational resources or pediatric-specific guidelines and protocols that are readily available at pediatric academic medical centers. The aim of this study is to evaluate adherence of community emergency departments in the state of Indiana to the pediatric DKA guidelines. Methods We performed a retrospective chart review of patients, age 18 years of age or under, admitted to the pediatric intensive care unit with a diagnosis of DKA. Results A total of 100 patients were included in the analysis. Thirty-seven percent of patients with DKA were managed according to all six guideline parameters. Only 39% of patients received the recommended hourly blood glucose checks. Thirty percent of patients received intravenous insulin bolus, which is not recommended. Conclusions Non-adherence to pediatric DKA guidelines still exists in the state of Indiana. Further, larger studies are needed to reveal the etiology of non-adherence to pediatric DKA guidelines and strategies to improve that adherence.
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Affiliation(s)
| | - Emily C Webber
- Department of Pediatrics, Section of Pediatric Hospital Medicine, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, 705 Riley Hospital Drive, ROC 4905, Indianapolis, IN, 46202-5225, USA
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Schenk E, Edgerton EA. A tale of two populations: addressing pediatric needs in the continuum of emergency care. Ann Emerg Med 2014; 65:673-8. [PMID: 25441766 DOI: 10.1016/j.annemergmed.2014.09.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 08/08/2014] [Accepted: 09/19/2014] [Indexed: 10/24/2022]
Abstract
Nearly 27% of all annual emergency department (ED) visits are pediatric related, a relatively small percentage in comparison to the number of visits from the adult population. The majority of the 31 million children and adolescents access care in nonpediatric facilities and have different clinical presentations and needs than adults. Administered by the Health Resources and Services Administration within the Department of Health and Human Services, the Emergency Medical Services for Children (EMSC) program is a federal entity that aims to ensure that pediatric care is well integrated into the entire emergency medical services system so that no matter where a child lives or travels, he or she can receive appropriate and timely care. The objective of this article is to describe the role of the EMSC program in the development of the pediatric emergency care system. The program is striving to improve pediatric emergency care in a number of ways: EMSC State Partnership grant performance measures address the ability of the out-of-hospital and hospital settings to care for children; the National Pediatric Readiness project works with EDs to ensure that essential resources are present to care for children; regionalization grants focus on the challenges of geographic isolation, access to specialty care, and limited resources; and the targeted issue grants focus on the care of the child in the out-of-hospital setting in which there is a paucity of evidence-based knowledge.
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Affiliation(s)
- Ellen Schenk
- Division of Child, Adolescent and Family Health, Maternal and Child Health Bureau, Health Resources and Services Administration, Department of Health and Human Services, Rockville, MD
| | - Elizabeth A Edgerton
- Division of Child, Adolescent and Family Health, Maternal and Child Health Bureau, Health Resources and Services Administration, Department of Health and Human Services, Rockville, MD.
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G Clark M, Dalabih A. Variability of DKA Management Among Pediatric Emergency Room and Critical Care Providers: A Call for More Evidence-Based and Cost-Effective Care? J Clin Res Pediatr Endocrinol 2014; 6:190-1. [PMID: 25241617 PMCID: PMC4293652 DOI: 10.4274/jcrpe.1434] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Management protocols have been shown to be effective in the pediatric emergency medicine (PEM) and pediatric critical care (PCC) settings. Treatment protocols define clear goals which are achieved with consistency in implementation. Over the last decade, many new recommendations have been proposed on managing diabetic ketoacidosis (DKA). Although no perfect set of guidelines exist, many institutions are developing DKA treatment protocols. We sought to determine the variability between institutions in implementation of these protocols.
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Affiliation(s)
- Matthew G Clark
- Missouri-Columbia University, Columbia, MO
,* Address for Correspondence: Missouri-Columbia University, Columbia, MO Phone: +57 3 6251949 E-mail:
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Koves IH, Leu MG, Spencer S, Popalisky JC, Drummond K, Beardsley E, Klee K, Zimmerman JJ. Improving care for pediatric diabetic ketoacidosis. Pediatrics 2014; 134:e848-56. [PMID: 25092935 DOI: 10.1542/peds.2013-3764] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE We sought to create and implement recommendations from an evidence-based pathway for hospital management of pediatric diabetic ketoacidosis (DKA) and to sustain improvement. We hypothesized that development and utilization of standard work for inpatient care of DKA would lead to reduction in hypokalemia and improvement in outcome measures. METHODS Development involved systematic review of published literature by a multidisciplinary team. Implementation included multidisciplinary feedback, hospital-wide education, daily team huddles, and development of computer decision support and electronic order sets. RESULTS Pathway-based order sets forced clinical pathway adherence; yet, variations in care persisted, requiring ongoing iterative review and pathway tool adjustment. Quality improvement measures have identified barriers and informed subsequent adjustments to interventions. We compared 281 patients treated postimplementation with 172 treated preimplementation. Our most notable findings included the following: (1) monitoring of serum potassium concentrations identified unanticipated hypokalemia episodes, not recognized before standard work implementation, and earlier addition of potassium to fluids resulted in a notable reduction in hypokalemia; (2) improvements in insulin infusion management were associated with reduced duration of ICU stay; and (3) with overall improved DKA management and education, cerebral edema occurrence and bicarbonate use were reduced. We continue to convene quarterly meetings, review cases, and process ongoing issues with system-based elements of implementing the recommendations. CONCLUSIONS Our multidisciplinary development and implementation of an evidence-based pathway for DKA have led to overall improvements in care. We continue to monitor quality improvement metric measures to sustain clinical gains while continuing to identify iterative improvement opportunities.
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Affiliation(s)
| | | | | | | | | | | | | | - Jerry J Zimmerman
- Critical Care Medicine, Seattle Children's Hospital, Seattle, Washington
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