Original ArticlesDiabetic Ketoacidosis Critical Care Pathway Implementation: Incorporation into EMR Significantly Decreases Length of Stay
Section snippets
INTRODUCTION
Diabetic ketoacidosis (DKA) is the combination of ketonemia, hyperglycemia, and hypovolemia in diabetic patients. Treatment involves intravenous insulin, fluid replacement, and correction of electrolyte abnormalities. Resolution is defined by normalization of acid-base disturbances, cessation of nausea and vomiting, and resumption of normal mental status. Prior to the discovery of insulin in 1920, DKA was universally fatal. In the 1930s, mortality was 29% (1), 1950s 10% (2), and today mortality
METHODS
Our institution's EMR (Epic Systems Corporation, Verona, WI) was used as the primary source for all clinical data. Standard query language (SQL) queries generated data from the EMRs' extracted relational database (Epic Clarity) to obtain the analyzed dataset. Primary DKA cases were identified from their hospital billing diagnoses using the International Classification of Diseases, ninth revision (ICD-9). ICD-9 billing codes of 250.1 and 250.1x (x representing any fifth digit) were included in
RESULTS
The analysis of 387 consecutive patients admitted between January 10, 2008 and May 31, 2014 revealed that the average historical LoS at our institution was 104 hours. After the DKA CCP was implemented, 48 consecutive patients admitted between July 24, 2014 and April 11, 2015 were found to have an average LoS of 73 hours (P = .0003) (Fig. 2). There was a higher percentage of patients with the anion gap reopening in the post-DKA CCP patients compared to the historical pre-DKA CCP patients (44%
DISCUSSION
The results of this study support the use of a DKA CCP at our institution as its implementation significantly lowered LoS. Secondary outcomes of hypoglycemia and hypokalemia while on the insulin drip did not worsen. However, a higher percentage of patients were found to have the anion gap reopen after DKA CCP implementation. This measure was intended to be a surrogate for failure of transition from intravenous to subcutaneous insulin. The reason for this finding is not clear.
Previous studies
CONCLUSION
Our institution's DKA CCP emphasized the same principles as earlier protocols, and the decrease in LoS was also comparable to previous findings. The DKA CCP was also translated into a 3-phased order set that worked well with our institution's EMR (Fig. 4).
DISCLOSURE
The authors have no multiplicity of interest to disclose.
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