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A Quality Improvement Initiative To Reduce Hospitalizations For Low Risk KAD - Pediatrics PDF
A Quality Improvement Initiative To Reduce Hospitalizations For Low Risk KAD - Pediatrics PDF
age with established T1D presenting to our tertiary care ED with low-risk Dr Bergmann conceptualized and designed the study,
DKA. Children transferred to our institution were excluded. DKA severity was developed the database, conducted the medical
record review, conducted the data analysis,
classified as low, medium, or high risk on the basis of laboratory and clinical participated in the interpretation of the results,
criteria. Our quality improvement initiative consisted of development and drafted the manuscript as written, and critically
implementation of an evidence-based treatment guideline after review by reviewed and revised the manuscript; Drs
Abuzzahab, Arms, Kharbanda, and Simper aided in
a multidisciplinary team. Our primary outcome was hospitalization rate, and the study concept and design, participated in the
our balancing measure was 3-day ED revisits. Statistical process control interpretation of the results, and critically reviewed
methods were used to evaluate outcome changes. and revised the manuscript; Drs Cutler, Christensen,
and Watson aided in the study concept and design,
RESULTS: Weidentified 165 patients presenting with low-risk DKA. The baseline performed the data analysis, participated in the
preimplementation hospitalization rate was 74% (95% confidence interval interpretation of the results, and critically reviewed
64%–82%), and after implementation, this decreased to 55% (95% and revised the manuscript; Ms Vander Velden
conducted the medical record review, aided in the
confidence interval 42%–67%) (219%; P = .011). The postimplementation development of the database, participated in the
hospitalization rate revealed special cause variation. One patient in the interpretation of the results, and critically reviewed
postimplementation period returned to the ED within 3 days but did not have and revised the manuscript; and all authors
approved the final manuscript as submitted and
DKA and was not hospitalized. agree to be accountable for all aspects of the work.
Hospitalization rates for children and young adults presenting to
CONCLUSIONS: DOI: https://doi.org/10.1542/peds.2019-1104
the ED with low-risk DKA can be safely reduced without an increase in ED Accepted for publication Nov 20, 2019
revisits. Address correspondence to Kelly R. Bergmann, DO,
Department of Emergency Medicine, Children’s
Minnesota, 2525 Chicago Ave South, Mail Stop 32-
1488, Minneapolis, MN 55404. E-mail:
Approximately 208 000 children in the that the mean cost of hospital kelly.bergmann@childrensmn.org
United States have type 1 diabetes admission for DKA is ∼$7140.5 Much of PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,
(T1D),1 and the incidence is increasing this cost is attributable to inpatient 1098-4275).
by 1.8% annually.1,2 Up to 30% of care, including treatment with Copyright © 2020 by the American Academy of
children present with diabetic intravenous (IV) insulin and admission Pediatrics
ketoacidosis (DKA) at initial diagnosis to an ICU.5,7
of T1D,3,4 and 20% to 47% have at least To cite: Bergmann KR, Abuzzahab MJ, Arms J,
1 subsequent readmission for DKA,5,6 Current treatment recommendations et al. A Quality Improvement Initiative to Reduce
Hospitalizations for Low-risk Diabetic Ketoacidosis.
resulting in substantial medical allow for variability in the care of
Pediatrics. 2020;145(3):e20191104
expenditure. Recent literature suggests children with DKA.8,9 As a result, there
Measures
Our primary outcome was the
proportion of children with low-risk
DKA who were hospitalized. Our
balancing measure was ED return
FIGURE 1
Key driver diagram. visits within 3 days of the index ED
visit. Secondary outcomes were the
proportion of children who received
standards were reviewed extensively 1 hour; standard dosing of 0.1 U/kg rapid or fast-acting subcutaneous
and incorporated into our treatment for administration of fast-acting insulin in the ED, ED length of stay
guideline. Our EBG was presented to subcutaneous insulin; and automated (LOS), and ED charges.
key stakeholders, including ED repeat point-of-care glucose checks
physicians, endocrinologists, 1 and 2 hours after insulin Study of the Intervention
intensive care physicians, and administration. Given that we wanted The hospitalization rate was
hospitalists, on multiple occasions. 1 order set for all children with DKA, monitored by using statistical process
Feedback from stakeholders was used including those with moderate or control methods.22,23 Specifically, the
to refine our treatment guideline severe (medium or high risk) DKA, percentages of hospitalizations were
through an iterative process. Our EBG we updated our order set to include assessed via p-charts.
was implemented in April 2016, treatment options for these patients.
which included placement of the In addition, we updated our ED Analysis
guideline on our intranet clinical discharge instructions for sick-day Patient characteristics before
guideline webpage, a nested link management for children treated with (January 1, 2012, to March 31, 2016)
within our ED DKA order set, and subcutaneous insulin and and after implementation (April 1,
printed version manually placed insulin pumps. 2016, to December 31, 2018) of the
within our 2 EDs to promote QI initiative were compared.
accessibility. Nursing and Provider Education
Differences in numeric and
Several nursing and provider change categorical data were assessed by
EMR Order Set and Discharge Updates strategies were used to promote using the Mann–Whitney U test and
Before our QI initiative, multiple shared awareness of and adherence x2 test (or Fisher’s exact test),
order sets specific to diabetes to our EBG. We conducted 5 nursing respectively. Hemoglobin A1C was
evaluation were available to ED education sessions during June 2016 reported as ,7.5% or $7.5%.24
providers. We reviewed all available and July 2017 to refine nursing skills
order sets and refined these to be and knowledge of T1D management, Because of small sample sizes within
more specific to presenting concerns. specifically subcutaneous and IV each quarter, sequential groups of 9
Through collaboration with insulin administration, and IV fluid consecutive patients were used for
Information Technology, we created management. These sessions included p-charts. Because of small sample
an ED DKA order set, which is case-based education using treatment sizes within each sequential group,
consistent with our EBG. Key updates recommendations from our EBG, the normal approximation to the
included the following: embedding hands-on training with trifuse IV binomial distribution did not apply.
our EBG within the order set for ease kits for fluid and medication Therefore, control limits for p-charts
of reference; integration of point-of- compatibility, education on insulin were calculated by using exact
care testing to shorten time to drip management, and education on binomial percentiles corresponding
laboratory results (ie, blood gas, signs of complications from insulin or to 2 and 3 SDs from the mean under
glucose, and electrolytes); options for IV fluid therapy (ie, hypoglycemia, a normal distribution (ie, 2.3 and 97.7
normal saline bolus amounts of altered mental status). To further percentiles and 0.1 and 99.9
10 mL/kg if the patient was increase the success of our EBG percentiles, respectively). Trial limits
#36 months or 20 mL/kg if the implementation, we held quarterly were calculated after 11 points,
patient was .36 months, given over presentations to ED physicians, corresponding to the
DISCUSSION
Through implementation of a QI
initiative, we safely reduced
hospitalization rates by an absolute
difference of 19% for children with
low-risk DKA, without an increase in
3-day ED revisits. Special cause
variation was seen after
implementation of a nursing
algorithm and nursing education,
suggesting that these efforts
influenced practice change. The total
FIGURE 2 adjusted mean charges were $13 022
Statistical process control chart revealing hospitalization rates by sequential groups of 9 consec- higher among children hospitalized
utive children presenting to the ED with low-risk DKA. Yellow and red control limits (CLs) correspond compared with those discharged from
to exact binomial percentiles corresponding to 2 and 3 SDs from the mean under a normal
distribution. the ED.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Funded in part by the Children’s Hospital Association.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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