Implementation and Evaluation of a Diabetic Ketoacidosis Order Set in Pediatric Type 1 Diabetes at a Tertiary Care Hospital: A Quality-Improvement Initiative

Introduction: Cardiac arrhythmias and arrest have been described in children with diabetic ketoacidosis and generally have been presumed to be caused by electrolyte abnormalities. The rationale of this study was to assess the role and importance of ECG monitoring, as a simple, quick, non-invasive and readily available tool in the diagnosis and confirmation of hypokalemia and hyperkalemia in patients with DKA in the Emergency Department Objective: To Assess the Frequency of electrocardiographic changes in Type-1 diabetes mellitus children with diabetic ketoacidosis presenting to tertiary care hospital, Karachi. Materials and Methods: This retrospective cross sectional study was carried out at the department of pediatric medicine, NICH Karachi. At the time of presentation, the standard 12-lead ECG was recorded by a single pediatric cardiologist having more than 2 years of experience, QT and RR intervals were measured. Three separate measurements were obtained from each ECG, and the mean of these measurements was used as the value for QTC. QTC of at least 0.45s (450ms) was considered as prolonged QTC. QTD was also assessed at the same time and QTD>50 ms was considered as prolonged QTD. Results: One hundred cases of T1DM with DKA were included in this study. Average age of children was 7.9 ±3.5 years (Min – Max = 0.5 – 14 years), male to female ratio was 1: 0.96. Prolong QTc and QTd interval was observed in (56%) and (38%) children respectively, Mean (±SD) QTc and QTd interval was 449.4 ±36.6 mc and 39.3 ±16.1 mc respectively. While ECG changes were found in (58%) cases. Association between ECG changes and the cases with higher RBS (>350 mg/dl) was statistically significant 81 (81%) cases with ECG changes had higher RBS (p<0.0001) while ECG changes were statistically similar in both age groups and gender (p-values > 0.05). Conclusion: The frequency of ECG changes was higher in T1DM children with diabetic ketoacidosis. ECG changes was significantly associated with higher RBS (>350 mg/dl). Key words: T1DM, Diabetic Ketoacidosis, ECG, QTc, QTd

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Frequency, precipitating factors and outcome of diabetic ketoacidosis in type 1 diabetes at tertiary care hospital

10.26226/morressier.59d51848d462b80296ca2f75 ◽

2017 ◽

Author(s):

Khan Muhammad Imran Hasan

Keyword(s):

Type 1 Diabetes ◽

Diabetic Ketoacidosis ◽

Tertiary Care Hospital ◽

Tertiary Care ◽

Care Hospital ◽

Precipitating Factors

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Comparison of outcome of milwaukee regimen and 48 hours regimen in diabetic ketoacidosis in a tertiary care hospital in Chitradurga, Karnataka, India

International Journal of Contemporary Pediatrics ◽

10.18203/2349-3291.ijcp20201651 ◽

2020 ◽

Vol 7 (5) ◽

pp. 1123

Author(s):

Basavanthappa S. P. ◽

Srinivasa V. ◽

Sivachand T.

Keyword(s):

Diabetic Ketoacidosis ◽

Tertiary Care Hospital ◽

Average Length ◽

Venous Blood ◽

Tertiary Care ◽

Medical Emergency ◽

Care Hospital ◽

Mortality And Morbidity ◽

Pediatric Age Group

Background: Diabetic ketoacidosis (DKA) is an acute life threatening and a medical emergency that accounts for the majority of diabetes related mortality and morbidity in the pediatric age group who are suffering from type 1 Diabetes Mellitus (DM). Objective of this study was to compare the clinical outcome in a patient with DKA who are been treated with Milwaukee regimen (24hours) and 48 hours regimen.Methods: A retrospective study was conducted in PICU of tertiary care hospital in Chitradurga, Karnataka. Data was collected from 2015 to May 2018. Diagnosis of DKA was made by plasma glucose level higher than 200mg/dl, venous blood PH of <7.3 and /or bicarbonate <15 mmol/L, presence of ketonuria. Among 56 cases, 36 cases were treated with 48 hours regimen and 20 cases were treated with Milwaukee regimen and results were compared.Results: The median age of presentation was 7.52 years (Range: 2-14 years) with female: male ratio of 1:1.3. Newly diagnosed type 1 DM cases constituted 80.7%. The most common presenting complaints were hurried breathing and altered sensorium. The average length of stay in the ICU was 3.5 days for 48 hours regimen and 4.5 days for Milwaukee regimen. The mortality rate was 10.71 % (6 cases), among which 15% (3 cases) were patients treated with Milwaukee and 8.3% (3 cases) were patients treated with 48 hours regimen. Cerebral edema was found to be the commonest cause of fatality.Conclusions: There is lack of awareness regarding dog bite and its management among the rural population.

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IMPROVING INITIATION OF KANGAROO MOTHER CARE IN A TERTIARY CARE HOSPITAL – A QUALITY IMPROVEMENT INITIATIVE

Indian Journal of Child Health ◽

10.32677/ijch.2019.v06.i11.011 ◽

2019 ◽

Vol 06 (11) ◽

pp. 617-619

Author(s):

Apoorva Taduri ◽

Himabindu Singh ◽

Swapna Lingaldinna ◽

Bharadwaj Namala

Keyword(s):

Quality Improvement ◽

Tertiary Care Hospital ◽

Tertiary Care ◽

Kangaroo Mother Care ◽

Quality Improvement Initiative ◽

Care Hospital

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IMPLEMENTATION AND EVALUATION OF A DKA ORDER SET IN A PEDIATRIC TERTIARY CARE HOSPITAL: A QUALITY IMPROVEMENT INITIATIVE

Paediatrics & Child Health ◽

10.1093/pch/pxy054.028 ◽

2018 ◽

Vol 23 (suppl_1) ◽

pp. e11-e11

Author(s):

Kayla Flood ◽

Munier Nour ◽

Vicki Cattell ◽

Tayna Holt ◽

Blair Seifert ◽

...

Keyword(s):

Quality Improvement ◽

Tertiary Care ◽

Evaluation Process ◽

Quality Improvement Initiative ◽

Care Hospital ◽

End User ◽

Paediatric Patients ◽

Tertiary Center ◽

The Impact ◽

Order Set

Abstract BACKGROUND Diabetic ketoacidosis (DKA) is a common clinical presentation in new and previously diagnosed paediatric patients with type 1 diabetes. In contrast to other Canadian tertiary paediatric hospitals, our center lacked a physician-endorsed evidence-informed care pathway for management of DKA. In the absence of a standardized approach to DKA, variability in patient management and outcomes were observed. This project was a quality improvement initiative that sought to develop and pilot a paediatric DKA order set. OBJECTIVES Our primary aim was to attain broad clinical uptake of the order set at our tertiary care center over a 12-month period. Secondary aims included improved standard-of-care DKA management: appropriate fluid bolus volume and maintenance rates; initial potassium management; and timely dextrose supplementation. DESIGN/METHODS A paediatric multidisciplinary collaborative was created to examine evidence for the development and implementation of a DKA order set. Implementation of the order set involved department wide education, targeted end-user education, and quarterly end-user review. A modified plan-do-study-act (PDSA) cycle guided by end-user feedback and early clinical outcomes allowed progressive order set modifications. RESULTS A retrospective chart review of fifty paediatric patients presenting to our center between April 2014 and September 2016 (pre-implementation) was compared to thirty paediatric patients presenting in DKA during the post-implementation phase (September 2016 – September 2017). There were no statistically significant differences in demographic and clinical characteristics between the groups. We achieved 83% uptake of the order set for patients presenting to our tertiary center and 67% uptake for patients transferred from peripheral centers. Improvements in DKA management included: appropriate intravenous (IV) maintenance fluid rates (20% vs. 48.3%, p=0.008), earlier administration of potassium to IV fluids (66% vs. 93.1%, p=0.006); appropriate potassium chloride dosing (40 mmol/L) to IV fluid (40% vs. 79.3%, p=0.0007) and earlier addition of IV dextrose (67.4% vs. 93.1%, p=0.009). No differences in moderate to severe hypokalemia (< 3.0 mmol/L), hypoglycemia (<4.0 mmol/L) or clinically suspected cerebral edema occurred. CONCLUSION Implementation of a DKA order set in a tertiary hospital required identification of key stakeholders, formation of a multidisciplinary team, and the development of an evaluation process. There was an observed increase in physician order set uptake and DKA management practice improvements. Future goals involve expanding the implementation and evaluation process to regional and remote centers and analyzing the impact on resource utilization.

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Clinical and biochemical profile of 786 sequential episodes of diabetic ketoacidosis in adults with type 1 and type 2 diabetes mellitus

BMJ Open Diabetes Research & Care ◽

10.1136/bmjdrc-2021-002451 ◽

2021 ◽

Vol 9 (2) ◽

pp. e002451

Author(s):

Emma Ooi ◽

Katrina Nash ◽

Lakshmi Rengarajan ◽

Eka Melson ◽

Lucretia Thomas ◽

...

Keyword(s):

Type 2 Diabetes ◽

Type 1 Diabetes ◽

Diabetic Ketoacidosis ◽

Tertiary Care ◽

Final Analysis ◽

Care Hospital ◽

Hospital Data ◽

Management Protocol

IntroductionWe explored the clinical and biochemical differences in demographics, presentation and management of diabetic ketoacidosis (DKA) in adults with type 1 and type 2 diabetes.Research design and methodsThis observational study included all episodes of DKA from April 2014 to September 2020 in a UK tertiary care hospital. Data were collected on diabetes type, demographics, biochemical and clinical features at presentation, and DKA management.ResultsFrom 786 consecutive DKA, 583 (75.9%) type 1 diabetes and 185 (24.1%) type 2 diabetes episodes were included in the final analysis. Those with type 2 diabetes were older and had more ethnic minority representation than those with type 1 diabetes. Intercurrent illness (39.8%) and suboptimal compliance (26.8%) were the two most common precipitating causes of DKA in both cohorts. Severity of DKA as assessed by pH, glucose and lactate at presentation was similar in both groups. Total insulin requirements and total DKA duration were the same (type 1 diabetes 13.9 units (9.1–21.9); type 2 diabetes 13.9 units (7.7–21.1); p=0.4638). However, people with type 2 diabetes had significantly longer hospital stay (type 1 diabetes: 3.0 days (1.7–6.1); type 2 diabetes: 11.0 days (5.0–23.1); p<0.0001).ConclusionsIn this population, a quarter of DKA episodes occurred in people with type 2 diabetes. DKA in type 2 diabetes presents at an older age and with greater representation from ethnic minorities. However, severity of presentation and DKA duration are similar in both type 1 and type 2 diabetes, suggesting that the same clinical management protocol is equally effective. People with type 2 diabetes have longer hospital admission.

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