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

1

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

2

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

3

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

4

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

5

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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16

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

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rom

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ide

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****

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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

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*

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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

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***

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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

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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)

24

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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