P2.N265: A Quality Improvement Initiative to Improve Emergency Care for Children and Adolescents With Medium and High Risk Diabetic Ketoacidosis

Purpose/Objectives: The primary aim of our quality improvement (QI) initiative was to increase the proportion of children who receive continuous insulin infusion by 10% and 2-bag intravenous (IV) fluids by 50% for children with type 1 diabetes (T1D) presenting to our emergency department (ED) with medium or high risk diabetic ketoacidosis (DKA) over a two-year period. The secondary aim was to increase the proportion of children who receive isotonic fluid bolus within 60 minutes, continuous insulin infusion within 120 minutes, and 2-bag IV fluids within 180 minutes by 10%, 20%, and 50%, respectively.

Design/Methods: We included children and young adults ≤21 years with T1D presenting to our tertiary care ED with medium or high risk DKA. The pre-intervention period spanned January 1, 2012 to March 31, 2016. The post-intervention period spanned April 1, 2016 to December 31, 2021 and included the period of QI interventions, which were implemented between April 1, 2016 to March 31, 2018. Interventions consisted of development and implementation of an evidence-based treatment guideline after review by a multi-disciplinary team, nursing education, and updates to the electronic medical record. DKA severity was classified as medium or high risk based on laboratory and clinical criteria. Encounters that were missing ≥1 laboratory value to confirm presence of DKA, and those transferred from an outside facility were excluded from analysis. Our primary outcome was treatment with isotonic fluid bolus, continuous insulin infusion, and 2-bag IV fluids. Statistical process control methods were used to evaluate outcome changes. Balancing measures included hypoglycemia < 70 mg/dL, and ED and hospital length of stay (LOS).

Results: We identified 4,626 encounters among children with T1D, of which 791 presented with medium or high risk DKA after applying exclusions, including 275 pre-intervention and 516 post-intervention (Table 1). The proportion of encounters that received continuous insulin increased from 89% to 94% (absolute difference 5%), and 2-bag IV fluids from 36% to 88% (absolute difference 52%) comparing pre- and post-intervention periods (Figure 1). The proportion that received isotonic fluid bolus within 60 minutes increased from 57% to 65% (absolute difference 8%), continuous insulin within 120 minutes from 20% to 30% (absolute difference 10%), and 2-bag IV fluids within 180 minutes from 36% to 60% (absolute difference 24%), comparing pre- and post-intervention periods (Table 1). The proportion of encounters with hypoglycemia, and ED and hospital LOS were similar comparing pre- and post-intervention periods (Table 1).

Conclusion/Discussion: We successfully increased the proportion of children with medium or high risk DKA treated with 2-bag IV fluids. Although we did not attain our goal of improving the time to isotonic fluid bolus, continuous insulin infusion, or 2-bag IV fluids, we observed meaningful improvement in the care of children with DKA.