ORLANDO – A new protocol for managing mild diabetic ketoacidosis in the emergency department led to a substantially improved discharge rate at a large teaching hospital.
Prior to development of the Emergency Valuable Approach and Diabetes Education (EVADE) protocol, almost all patients who presented with diabetic ketoacidosis (DKA) were admitted to the hospital, and most of those were admitted to the intensive care unit. However, in the most recent month for which outcomes data for the EVADE protocol are available, 24 of 106 patients (23%) managed according to the protocol were discharged from the ED and 82 were admitted, Marianne Chojnicki, a registered nurse and certified diabetes educator at the Joslin Diabetes Center, Boston, reported at the annual meeting of the American Association of Diabetes Educators.
The average length of stay in the ED for those who were discharged was 20 hours. The average length of stay in the hospital for 23 patients with a non-ICU admission was 136 hours, and the average length of stay in the ICU for 59 patients with an ICU admission was 33 hours, followed by 77 hours in the hospital after ICU discharge.
The findings have important implications for the care of patients presenting with DKA, which is documented in up to 9% of all hospital discharge summaries among patients with diabetes, and which is associated with mortality of up to 2%, Ms. Chojnicki noted.
"That’s a significant number of lives that are lost each year from a preventable event," she said.
In an effort to improve the discharge rate to at least 10%, Joslin Diabetes Center physicians, nurses, and diabetes educators worked together with Beth Israel Deaconess Medical Center in Boston to develop the EVADE protocol, which stemmed from a clinical approach used to manage DKA, and which is initiated in the ED based on clinical triggers.
They thought that a significant number of admissions were avoidable in a well-managed, coordinated system. The goal was to provide optimal cost-effective management for DKA, Ms. Chojnicki said.
From the outset, diabetes education was recognized as a key component of this protocol, she noted.
The education is individualized and covers multiple topics, such as identification of the circumstances leading up to DKA, a review of insulin action and technique of administration, and a review of ways to prevent DKA recurrence.
Evaluating the EVADE protocol
To evaluate the effectiveness of the protocol, a system was put in place to identify all patients who presented to the ED with blood glucose higher than 300 mg/dL and bicarbonate of 20 mEq/L or less. The patients were flagged for enrollment to be managed according to the EVADE protocol if their status was determined to be caused by DKA, and if they consented.
This process began in September 2013, and the first several months were spent refining management and defining quality indicators.
Month 8 results suggest that the protocol is effective for increasing discharge rates and reducing ICU admissions.
"Our initial goal was to discharge 10%, so we are above goal," Ms. Chojnicki said.
Overall, patients with mild to moderate DKA are going home from the ED, she said.
Typically, those with moderate DKA are admitted if they have a secondary diagnosis, and those patients are going to non-ICU beds.
"Only the sickest of the sick – basically those who are acidotic – are the patients going to the ICU," she said.
Preliminary data from an ongoing review of the results by a health economist show that despite the fact that the sickest patients are going to the ICU, the number of ICU days is decreasing in the wake of the EVADE protocol implementation.
This seems counterintuitive, but the latest data show that before EVADE, the average time spent in the ICU was 47.8 hours, and after EVADE the average time spent in the ICU was 31.6 hours.
"We shaved off 16.2 hours in one of the highest-cost areas of the hospital," Ms. Chojnicki said.
Notably, only one patient who was treated according to the EVADE protocol returned to the ED within 30 days, and that was a patient with issues related to alcohol abuse, she noted.
The findings suggest that mild DKA can be optimally managed in the setting of identification of the triggering factor, stabilization of glucose and electrolyte imbalances, patient education, and close follow-up, and that such management allows for more patients to be discharged from the ED, she said.
Ms. Chojnicki reported having no disclosures.
The EVADE protocol, step by step
The EVADE protocol for eligible patients begins with initiation of intravenous fluids but withholding insulin until initial labs are available. Once lab results confirm diabetic ketoacidosis, the staff initiates IV insulin.