ESPE Yearbook of Paediatric Endocrinology

To read the full abstract: Pediatrics 144, number 4, October 2019:e20182984

Diagnostic delays in the pediatric emergency department (ED) can lead to unnecessary interventions, prolonged length of hospital and emergency department stay (LOS) and even death. This is especially true in diabetic patients presenting with possible diabetic ketoacidosis (DKA). At one institution, DKA determination time (from arrival to diagnosis) was 86 minutes, and 61% of patients did not meet the criteria for DKA. As a result, intravenous (IV) placement occurred in 85% of patients without DKA. This study evaluated the implementation of four key interventions (point-of-care (POC) testing, order panels, provider guidelines, and nursing guidelines) to reduce DKA determination time from 86 minutes to a target 30 minutes, and IV placements in patients without DKA from 85% to target level 20% over 18 months.

Between 2015 and 2018, 783 patients with diabetes mellitus were evaluated for DKA. After all four interventions, DKA determination time decreased from 86 to 26 minutes (P <0.001). In patients without DKA, IV placement decreased from 85% to 36% (P <0.001). ED LOS decreased from 206 to 186 minutes (P =0.009) in patients discharged from the hospital after DKA evaluation. POC testing and order panel use increased from 0% to 98% and 90%, respectively. This study shows that using quality-improvement methodology (plan-do-study-act cycles), a meaningful and clinically relevant reduction in DKA determination time, percentage of IV placements, and ED LOS can be achieved.

However, this study also shows that improving quality of care in the ED can be difficult. POC testing of pH and bicarbonate was one crucial step to improve management. However, possibly the data should not be extrapolated to smaller European pediatric diabetes centers, where ketone POC measurements in diabetic patients with typical symptoms of DKA might be sufficient. Written standardised guidelines and repeated training and education of ED staff would most likely improve DKA management and reduce complications and mortality in most health care settings around the world.