Improving diabetic ketoacidosis management while reducing cost of care through quality
improvement programme
Punith Kempegowda
Specialist Registrar Trainee in Endocrinology, Diabetes and General Internal Medicine
University Hospitals Birmingham NHS Foundation Trust
Health Education West Midlands
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Layout of the presentation
• History of Birmingham and diabetes
• Background to the QIP
• Quality Improvement in Medicine and its application in our project
• Methods and interventions
• Results
• Summary
• Current and future directions
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Birmingham and Diabetes
John Malins
Michael FitzGerald
Malcolm Nattrass
Alexander D Wright
• Professor John Malins • Largest diabetic clinic in Britain in 1940’s
• Dr Michael FitzGerald • Dedicated inpatient ward for diabetes
• Dr Malcolm Nattrass • First qualifications for diabetes specialist
nurses
• Dr Alex Wright • UK Prospective Diabetes Study
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Background
• Diabetic ketoacidosis (DKA)- extreme metabolic state due to insulin deficiency.
• Diagnosed with glucose≥11 mmol/L, ketones≥3 mmol/L and pH≤7.3 or bicarbonate≤15 mmol/L
• A single episode of DKA associated with 5.2% risk of death and 23.4% with recurrent DKA
• Joint British Diabetes Society (JBDS) guidelines in 2010; further revised in 2013
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Quality Improvement (QI) in medicine
• Current methods to audit DKA management lack sustained and nationally replicable model
• QI is a systematic approach to analyse efforts to improve performance
• Royal College of Physicians Learning to make a Difference Programme
• Health Education England’s Making Every Moment Count
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Background- continued
• NHS RightCare
• Making the NHS’s money go as far as possible and improving patient outcomes.
• Design is important and needs to be thought about in terms of delivering quality of care
• Information is powerful and letting people see data will change behaviour
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Hypothesis
Implementing a QI for limited clinical criteria and frequent feedback improves DKA management
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Methods
• All patients diagnosed with DKA from April 2014 to September 2016 were included.
• Patients managed in intensive care units were excluded from the study to avoid one-to-one care bias.
• We adopted the plan-do-study-act (PDSA) method for the QIP
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Outcome
Primary driver
Primary driver
Primary driver
Secondary driver
Secondary driver
Secondary driver
Secondary driver
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• Fluids • Fixed rate insulin infusion (FRII) • Glucose measurements • Ketone measurements • Specialist referral
Duration of DKA
Emergency department Diagnosis Initiation of treatment Transfer to Acute Medicine
Department of Diabetes Early referral Discharge planning Follow-up
Clinical • Emergency medicine • Acute medicine • Department of diabetes
Non-clinical • Bed management • Clinical governance • Information-technology
Bed management Transfer of patients from ED to CDU and then to appropriate ward
Clinical Governance Permit to undertake the QIP and approve amendments in the guidelines
Information technology Optimising all referrals and providing appropriate patient list
Acute Medicine Confirming diagnosis Optimising treatment Hourly measurements
Mar 2015- Revamping DKA protocol Jan 2015- Blood gases on electronic patient records
Feb 2015- Introducing DKA mnemonic Oct 2014- QIP initiated Dec 2014- FRII and hourly measurements
Nov 2014- Automatic Referral and fluid
Act
Plan
Study
Do
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Diabetes Charts: post QIP Diabetes Charts: 2014
Methods- continued
• Baseline audit
• Five specific targets (primary drivers: fluid prescription, fixed rate insulin infusion, glucose measurement, ketone measurement and specialist referral)
• Interventions (secondary drivers) through PDSA cycles
• monthly feedback to departments of emergency medicine, acute medicine, and diabetes.
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Methods- continued
• Data about patient demographics and the selected parameters during the first 12 hours following the diagnosis of DKA.
• The study period was divided into five distinct periods
• Pre-intervention (April 2014 to September 2014)
• Intervention (October 2014 to March 2015)
• Early follow- up (April 2015 to September 2015)
• Intermediate follow-up (October 2015 to March 2015)
• Late follow-up (April 2016 to September 2016)
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Results
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Fixed rate intravenous insulin infusion
• Insulin replacement will switch off lipolysis, the main driver of metabolic acidosis in DKA.
• Guidelines recommend weight-based FRIII (calculated as 0.1 units/kg body weight) to accommodate insulin-resistant states associated with obesity or pregnancy.
Pre
-interv
ention
Interventio
n
Early fo
llow-u
p
Intermediate fo
llow-u
p
Late follo
w-up
-100
0
100
200
Pe
rce
nta
ge
de
via
tio
n f
rom
gu
ide
lin
e
****
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Fluids
• Fluid replacement is the most important initial management.
• Guidelines suggest at least four litres of fluid replacement in the first 12 hours (1,000 mL in the first hour, 2,000 mL over the next four hours and a further 2,000 mL over the next eight hours).
Pre-in
terventio
n
Interventio
n
Early fo
llow-u
p
Intermediate fo
llow-u
p
Late follo
w-up
-100
0
100
200
Pe
rce
nta
ge
de
via
tio
n f
rom
gu
ide
lin
e
*
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Glucose measurement
• Glucose falls sharply with insulin infusion; therefore, hourly glucose measurement is required.
• Supplementary glucose infusion may be required at the latter stages of DKA management to provide substrate and avoid hypoglycaemia until ketone production is completely switched off.
Pre-in
terventio
n
Interventio
n
Early fo
llow-u
p
Intermediate fo
llow-u
p
Late follo
w-up
-100
0
100
200
Pe
rce
nta
ge
de
via
tio
n f
rom
gu
ide
lin
e
***
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Ketone measurement
• Guidelines recommend hourly ketone measurement to assess the adequacy of insulin replacement and also assess for resolution.
• Further titration of insulin infusion to aim for a reduction in blood ketone levels by approximately 0.5 mmol/L/hour.
Pre-in
terventio
n
Interventio
n
Early fo
llow-u
p
Intermediate fo
llow-u
p
Late follo
w-up
-100
0
100
200
Pe
rce
nta
ge
de
via
tio
n f
rom
gu
ide
lin
e
ns
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Pre-in
terventio
n
Interventio
n
Early fo
llow-u
p
Intermediate fo
llow-u
p
Late follo
w-up
0
20
40
6080
120
160
Ho
urs
DKA duration
ns
***
****
***
DKA duration
• The total duration of DKA (from the time of diagnosis to the time of biochemical resolution) reduced significantly following our intervention from 22.0 to 18.3 to 12.0 to 7.4 at its nadir and 10.2 hours in the late follow-up period.
Results- continued
• The average healthcare cost in acute medical unit is £14.1 per hour.
• Cost for DKA resolution reduced from £22,338.50 pre-intervention to £6,489.50 in the late follow-up period.
• Quicker resolution helped free up acute medical beds for other ill patients.
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Diagnosticcriteria
Allthreeofthefollowingshouldbepresent:1. Capillarybloodglucose>11mmol/L orhistoryofdiabetes
(glucosemaybe 11mmol/Lineuglycaemic ketoacidosis)2. Capillaryketone>3mmol/Lorurineketones>2+.3. VenouspH<7.3and/orbicarbonate<15mmol/L.
0-60minutes
60minutesto6hours
6-12hours
12-24hours
Restorecirculatingvolume• Give500mlbolusof0.9%sodiumchlorideinfusionuntilsystolicBPis>90mmHg
• OncesystolicBP>90mmHg,Give1Lof0.9%sodiumchlorideoveronehour.
Reassesspatientandcontinuemonitoring:• Hourlybloodketoneand
glucosemonitoring• VenousgasforpH,
bicarbonateandpotassiumatendofeachfluidbag
Reassessandmonitorvitalsigns:• Seekseniormedicaladviceifpatientnotimproving
• Ifglucose<14mmol/Lstart10%glucoseat125mls/hralongsidesodiumchloride
• DKAshouldhaveresolvedbynow• Reassessandmonitorvitalsigns
ResolutionofDKA• Resolutionisdefinedasketoneslessthan0.6mmol/Land
venouspHover7.3• IfDKAhasresolved-o converttos/cinsulinifpatienteatinganddrinkingwello Switchtovariablerateintravenousinsulininfusionifpatient
isunwellorunabletoeatanddrink
*PotassiumsupplementationThisshouldbeaccordingtobloodK+(mmol/L):• >5.5:Nopotassiumreplacement• 3.5-5.5:40mmolperlitreofinfusionfluid• <3.5:seniorreviewtoassesstherisksandbenefitsof
replacement
StartInsulintherapy:• Startfixedrateinsulininfusionat0.1ml/kg/hr (prescribedasActrapid Inf DKAonPICS).
• Continuepatient’slongactingsubcutaneousinsulin
Initiatemonitoring• Hourlycapillaryglucose• Hourlycapillaryketones• Venousbicarbonateand
potassiumat60minutes,2hoursand2hourlythereafter.
• 4hourlyplasmaelectrolytes
Continuefluidmanagement:• 1L0.9%sodiumchloridewith
potassium*,over2hours• 1L0.9%sodiumchloridewith
potassium*,over2hours• 1L0.9%sodiumchloridewith
potassium*,over4hours
AssessthepatientsresponseChangeInfusionrateif:• Ketonesnotfallingat0.5mmol/hr• Bicarbonatenotrisingby
3mmol/hr• Glucosenotfallingby3mmol/hr
Continuefluidmanagement:• 1L0.9%sodiumchloridewithpotassium*,over4hours
• 1L0.9%sodiumchloridewithpotassium*,over6hours
• Reassessat12hours
ReviewMetabolicparameters:• At12hourscheckvenouspH,bicarb,potassium,aswell
asketonesandglucose.• CheckifDKAhasresolved.Ifnotseeksenioradvice.
Whentorefertocriticalcareunit• Young(18-25)orelderly• Pregnancy• Heartorliverorkidneyfailure• SevereDKAjudgedby:bloodketones>6mmol/l,
bicarb<5mmol/l,pH<7.1,hypokalaemia,GCS<12,SpO2<92%,brady/tachycardiaoraniongap>16
ReviewMetabolicParameters:• Continuehourlybloodketone
andglucosemonitoring• VenousgasforpH,bicarbonate
andpotassiumatendofeachfluidbag
RuleoutEuglycaemic ketoacidosis andHyperglycaemicHyperosmolarState (HHS)inhighriskacutelyunwellpatientswithdiabetes(Eg:Pregnancy,thoseonSGLT-2inhibitors(gliflozins)
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Diagnosticcriteria
Allthreeofthefollowingshouldbepresent:1. Capillarybloodglucose>11mmol/L orhistoryofdiabetes
(glucosemaybe 11mmol/Lineuglycaemic ketoacidosis)2. Capillaryketone>3mmol/Lorurineketones>2+.3. VenouspH<7.3and/orbicarbonate<15mmol/L.
0-60minutes
60minutesto6hours
6-12hours
12-24hours
Restorecirculatingvolume• Give500mlbolusof0.9%sodiumchlorideinfusionuntilsystolicBPis>90mmHg
• OncesystolicBP>90mmHg,Give1Lof0.9%sodiumchlorideoveronehour.
Reassesspatientandcontinuemonitoring:• Hourlybloodketoneand
glucosemonitoring• VenousgasforpH,
bicarbonateandpotassiumatendofeachfluidbag
Reassessandmonitorvitalsigns:• Seekseniormedicaladviceifpatientnotimproving
• Ifglucose<14mmol/Lstart10%glucoseat125mls/hralongsidesodiumchloride
• DKAshouldhaveresolvedbynow• Reassessandmonitorvitalsigns
ResolutionofDKA• Resolutionisdefinedasketoneslessthan0.6mmol/Land
venouspHover7.3• IfDKAhasresolved-o converttos/cinsulinifpatienteatinganddrinkingwello Switchtovariablerateintravenousinsulininfusionifpatient
isunwellorunabletoeatanddrink
*PotassiumsupplementationThisshouldbeaccordingtobloodK+(mmol/L):• >5.5:Nopotassiumreplacement• 3.5-5.5:40mmolperlitreofinfusionfluid• <3.5:seniorreviewtoassesstherisksandbenefitsof
replacement
StartInsulintherapy:• Startfixedrateinsulininfusionat0.1ml/kg/hr (prescribedasActrapid Inf DKAonPICS).
• Continuepatient’slongactingsubcutaneousinsulin
Initiatemonitoring• Hourlycapillaryglucose• Hourlycapillaryketones• Venousbicarbonateand
potassiumat60minutes,2hoursand2hourlythereafter.
• 4hourlyplasmaelectrolytes
Continuefluidmanagement:• 1L0.9%sodiumchloridewith
potassium*,over2hours• 1L0.9%sodiumchloridewith
potassium*,over2hours• 1L0.9%sodiumchloridewith
potassium*,over4hours
AssessthepatientsresponseChangeInfusionrateif:• Ketonesnotfallingat0.5mmol/hr• Bicarbonatenotrisingby
3mmol/hr• Glucosenotfallingby3mmol/hr
Continuefluidmanagement:• 1L0.9%sodiumchloridewithpotassium*,over4hours
• 1L0.9%sodiumchloridewithpotassium*,over6hours
• Reassessat12hours
ReviewMetabolicparameters:• At12hourscheckvenouspH,bicarb,potassium,aswell
asketonesandglucose.• CheckifDKAhasresolved.Ifnotseeksenioradvice.
Whentorefertocriticalcareunit• Young(18-25)orelderly• Pregnancy• Heartorliverorkidneyfailure• SevereDKAjudgedby:bloodketones>6mmol/l,
bicarb<5mmol/l,pH<7.1,hypokalaemia,GCS<12,SpO2<92%,brady/tachycardiaoraniongap>16
ReviewMetabolicParameters:• Continuehourlybloodketone
andglucosemonitoring• VenousgasforpH,bicarbonate
andpotassiumatendofeachfluidbag
RuleoutEuglycaemic ketoacidosis andHyperglycaemicHyperosmolarState (HHS)inhighriskacutelyunwellpatientswithdiabetes(Eg:Pregnancy,thoseonSGLT-2inhibitors(gliflozins)
Summary
• In our study, we were able to demonstrate a significant and sustained reduction in DKA.
• We attribute this to improvements through PDSA and regular feedback of performance to stakeholders.
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Act
Plan
Study
Do
Current and future directions
• We are currently assessing the long term outcome of the QIP at our trust
• Plans for similar QIPs to improve outcome for other diabetes and endocrine conditions
• We propose that the primary drivers for improvement in DKA resolution time be tested in other trusts to confirm reproducibility.
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Acknowledgements • Parth Narendran- Consultant, Department of Diabetes, QEHB
• Sandip Ghosh- Consultant, Department of Diabetes , QEHB
• Wasim Hanif- Consultant, Department of Diabetes , QEHB
• Wiebke Arlt- Consultant, Department of Endocrinology , QEHB
• Muhammad Ali Karamat- Consultant, Department of Diabetes, BHH
• Umesh Salanke- Consultant, Emergency Medicine , QEHB
• Mohammed Akber- Consultant, Acute Medicine , QEHB
• Peter Nightingale- Statistician, Institute of Translational Medicine
• Anitha Vijayan Melapatte- health informatics , QEHB
• Ben Coombs, Joht Singh Chandan, Jaffar Al-Sheikhli, Bhavana Shyamanur, Kasun Theivendran- Junior doctors , QEHB
• Diabetes Specialist nurses, Queen Elizabeth Hospital Birmingham
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