Evaluating an Order Set for the Improvement of Quality Outcomes in Diabetic Ketoacidosis

Monday, 30 October 2017: 9:50 AM

Ann Marie Blair-Joyner, MSN
Glycemic Management and Transitional Care, Columbus Regional Health/Midtown Medical Center, Columbus, GA, USA
Bernita Hamilton, PhD
School of Nursing, Troy University, Montgomery, AL, USA
Amy Yoder Spurlock, PhD, RN
School of Nursing, Troy University, Troy, AL, USA

The purpose of this project was to determine if utilization of an evidence-based order set versus an individualized provider approach for the treatment and management of diabetic ketoacidosis (DKA) improves outcomes, decreases healthcare expenditures, and prevents the occurrence of hospital acquired conditions or manifestation of poor glycemic control.

Ketoacidosis, a serious metabolic derangement, can occur in type 1 and type 2 diabetes (DynaMed Plus, 2016). The appropriate and timely management of DKA is essential to avoid lengthy hospitalizations and poor clinical outcomes. Appropriate and timely management will reliably improve clinical outcomes and decrease healthcare expenditures (Janakiram et al., 2015). In 2012 the number of new cases of diabetes in the United States was approximately 1.7 million in those 20 years of age or older and 208,000 in those less than 20 years of age (Centers for Disease Control and Prevention, 2014). Patients with diabetes are at risk for development of DKA, which can be fatal if not appropriately treated (Alourfi & Homsi, 2015).

Evidence supports use of evidence-based DKA protocols (Evans et al., 2014; Janakiram et al, 2014). Team approaches in the development of a proposed protocol will likely increase acceptance, implementation, and application. The consistent application of an evidence-based approach for the management of diabetic ketoacidosis will solidify a health system’s unity of direction and commitment to excellence.

Despite the evidence and the availability of evidence-based protocols there remains inconsistency and variation in the approach to managing inpatient hyperglycemia and DKA among healthcare providers. There is often an absence of ownership for glycemic management in hospitalized patients, most notably in those with a diagnosis other than diabetes. This absence may be ascribed to knowledge deficits affecting provider confidence. Education and training on treatment and management will lead to an improvement in care and outcomes (DynaMed Plus, 2016).

Anticipated project outcomes include improved clinical outcomes and decreased healthcare expenditures when treating patients with diabetic ketoacidosis. An institutionally approved DKA order set was evaluated using the following variables (a) time to insulin therapy initiation, (b) fluid and electrolyte therapy replacement, (c) glycemic variability with an increased percent of glucose readings within target range, (e) transition from intravenous insulin infusions to subcutaneous insulin, (f) length of hospital stay, (g) care transition; and (h) DKA readmissions.

The setting for project implementation is a Level II Trauma Center/Emergency Department and/or critical care unit of a 500-bed acute care academic medical center located in West Central Georgia. Project stakeholders include pharmacy, nursing, institutional and community providers, laboratory services, nutrition services, payers, patient/patient support, leadership, and ancillary services.

A pre-intervention and post-intervention retrospective review of the electronic medical record (EMR) of 150 non-pregnant adult patients diagnosed with DKA was performed upon receipt of project approval by the Troy University Institutional Review Board (IRB). The approval to perform this study, to include access to individual electronic medical records, has been awarded by the institution’s Research Integrity Panel, the institution’s Chief Privacy Officer and the Troy University IRB.

Electronic medical records were identified through the generation of a report containing ICD-10 codes appropriate for the diagnosis of DKA and/or insulin infusion orders. Reported data will be obtained through abstraction from the EMR by the primary investigator. Each EMR will be assigned a unique identifier (UI) to protect personal health information (PHI). There will be no reference to medical record numbers, names, birth dates, date of service, or any other identifying data elements. The UI will include the month, date, and year of hospitalization with a corresponding number reflecting the order of review, e.g. 2016010201 (February 1, 2016, EMR 1).

 Short, medium, and long-term effects were identified. Short term effects include provider education. Medium term effects include demonstrated support for protocol utilization, communication of project milestones to demonstrate the progress made, and policy supporting adherence to evidence-based practice. The anticipated long term effects from this project include an improvement in healthcare practices and services provided to patients with DKA, improved glycemic control evidenced by a reduced time to insulin therapy initiation, appropriate transition from intravenous insulin infusions to subcutaneous insulin, decreased glycemic variability, quality improvement, improved glycemic control (percent of glucose readings within target range), the avoidance of hospital acquired conditions, appropriate care transition and a reduction in DKA readmission, all contributing to a long-term reduction in health care expenditures.

Glycemic control in the critically ill and the appropriate management of inpatient hyperglycemia stands cost-effective (Moghissi et al., 2009). Evidence-based practice will not be implemented or become standard if it is perceived as difficult or rigid. The implementation and preservation of evidence-based practice requires a multidisciplinary commitment and representation at the unit level with the support of administration.