title: Improving care for pediatric diabetic ketoacidosis.
abstract: OBJECTIVE
  We sought to create and implement recommendations from an evidence-based pathway for hospital management of pediatric diabetic ketoacidosis (DKA) and to sustain improvement. We hypothesized that development and utilization of standard work for inpatient care of DKA would lead to reduction in hypokalemia and improvement in outcome measures.
  
  
  METHODS
  Development involved systematic review of published literature by a multidisciplinary team. Implementation included multidisciplinary feedback, hospital-wide education, daily team huddles, and development of computer decision support and electronic order sets.
  
  
  RESULTS
  Pathway-based order sets forced clinical pathway adherence; yet, variations in care persisted, requiring ongoing iterative review and pathway tool adjustment. Quality improvement measures have identified barriers and informed subsequent adjustments to interventions. We compared 281 patients treated postimplementation with 172 treated preimplementation. Our most notable findings included the following: (1) monitoring of serum potassium concentrations identified unanticipated hypokalemia episodes, not recognized before standard work implementation, and earlier addition of potassium to fluids resulted in a notable reduction in hypokalemia; (2) improvements in insulin infusion management were associated with reduced duration of ICU stay; and (3) with overall improved DKA management and education, cerebral edema occurrence and bicarbonate use were reduced. We continue to convene quarterly meetings, review cases, and process ongoing issues with system-based elements of implementing the recommendations.
  
  
  CONCLUSIONS
  Our multidisciplinary development and implementation of an evidence-based pathway for DKA have led to overall improvements in care. We continue to monitor quality improvement metric measures to sustain clinical gains while continuing to identify iterative improvement opportunities.
authors.affiliation: Division of Endocrinology and Diabetes, ildiko.koves@seattlechildrens.org.
authors.forename: Ildiko H
authors.initials: IH
authors.lastname: Koves
authors.affiliation: Hospital Medicine, Clinical Effectiveness.
authors.forename: Michael G
authors.initials: MG
authors.lastname: Leu
authors.affiliation: Clinical Effectiveness, Knowledge Management.
authors.forename: Suzanne
authors.initials: S
authors.lastname: Spencer
authors.affiliation: Clinical Effectiveness.
authors.forename: Jean C
authors.initials: JC
authors.lastname: Popalisky
authors.affiliation: Clinical Effectiveness.
authors.forename: Kate
authors.initials: K
authors.lastname: Drummond
authors.affiliation: Emergency Department.
authors.forename: Elaine
authors.initials: E
authors.lastname: Beardsley
authors.affiliation: Inpatient Medical Unit, and.
authors.forename: Kristi
authors.initials: K
authors.lastname: Klee
authors.affiliation: Critical Care Medicine, Seattle Children's Hospital, Seattle, Washington.
authors.forename: Jerry J
authors.initials: JJ
authors.lastname: Zimmerman
mesh_terms: D016883:Diabetic Ketoacidosis / Q000175:diagnosis* / Q000453:epidemiology / Q000628:therapy*; D019468:Disease Management; D006760:Hospitalization; D006801:Humans; D005791:Patient Care / Q000379:methods / Q000592:standards*
keywords: computerized physician order entry; electronic medical record; pediatric diabetic ketoacidosis; quality improvement; standardization