A reaudit of the management of diabetic ketoacidosis after the introduction of a local protocol based on the JBDS guidelines: then and now

Abstract

Background: In 2010 the Joint British Diabetes Societies Inpatient Care Group issued guidelines for the management of Diabetic Ketoacidosis. A new management guideline and bedside chart based on these guidelines were introduced in our Health Board in 2012.

Methods: A retrospective re-audit of 33 patients managed according to the new guideline, admitted from October 2013 to October 2014. Results were compared to 2010 prior to implementation of the guideline and the first audit cycle September 2012 to 2013 immediately after.

Results: 3 admissions a month. Median age was 34 years, 94% admitted with established DKA and vomiting (70%), as the commonest presenting symptom. Length of stay: median of 2 days, with mortality of 0%. Median time to IV fluids: 35 (2 – 420) minutes, time to fixed rate intravenous insulin infusion: 40 (2 to 210) minutes. Long acting insulin continued in 94% with 21% hypoglycaemia (n=7) and 6% hypo-kalaemia rates (n=2). Median time to resolution of ketosis: 12 hours. Variable rate insulin started in 55% post DKA protocol, due to ongoing nausea and vomiting.100% of patients were reviewed by the inpatient diabetes care team.

Conclusions: Sustained improvements in median times to insulin, fluids and >50% reduction in hypoglycaemia. Reduced time on intravenous insulin compared to pre guideline in 2010 with an objective end point for resolution of ketoacidosis. Bedside potassium monitoring remains suboptimal.