Impact of diabetic ketoacidosis management in the medical intensive care unit after order set implementation.
OBJECTIVE
To determine the rate of compliance to the 2006 and 2009 ADA DKA guidelines in the medical intensive care unit (MICU) at a large academic medical centre after the implementation of a computerised DKA order set and protocol.


METHODS
Retrospective chart review of adult patients with DKA admitted to the MICU. Results of pre-order set (PRE) were compared to those of data post-order set (POST). The primary outcome was a composite administration of intravenous fluid resuscitation in the first 24 h, insulin bolus and initial insulin infusion rate.


RESULTS
Twelve of 60 patients (20%) in the PRE group received treatment compliant with the 2006 guidelines versus 14 of 55 patients (25.5%) in the POST group (OR 1.22 95% CI 0.44 to 3.4, P = 0.51). Compliance to the 2009 guidelines was significantly higher in the POST group (31.7% versus 65.5%, OR 4.44 95% CI 1.8 to 10.92, P = 0.0004). Compliance for individual components was 26.7% versus 70.9% for fluid resuscitation (P = 0.0001), 55% versus 49.1% for insulin bolus (P = 0.58) and 60% versus 81.3% for initial insulin infusion rate (P = 0.014), respectively. Time to DKA resolution was decreased (P = 0.04), and hypoglycaemia was increased (P = 0.0022).


CONCLUSIONS
Implementation of a computerised DKA order set and protocol was associated with improved compliance to the 2009 ADA DKA guidelines, 24-h fluid resuscitation, initial insulin infusion rate, time to DKA resolution and appropriate transition to subcutaneous insulin. However, patients in the POST implementation group were more likely to exhibit hypoglycaemia. Future assessment is warranted.
Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA.
Benjamin
B
Laliberte
Department of Pharmacy Services, University of Maryland Medical Center, Baltimore, MD, USA.
Siu Yan Amy
SYA
Yeung
Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA.
Jeffrey P
JP
Gonzales
D000046:Academic Medical Centers; D000328:Adult; D000368:Aged; D003422:Critical Care / Q000379:methods*; D016883:Diabetic Ketoacidosis / Q000188:drug therapy*; D005260:Female; D005440:Fluid Therapy; D019983:Guideline Adherence; D006801:Humans; D007003:Hypoglycemia / Q000139:chemically induced / Q000453:epidemiology; D007004:Hypoglycemic Agents / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use; D007328:Insulin / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use; D007362:Intensive Care Units; D008297:Male; D008510:Medication Systems, Hospital / Q000458:organization & administration*; D008875:Middle Aged; D012151:Resuscitation; D012189:Retrospective Studies; D016896:Treatment Outcome
D007004:Hypoglycemic Agents; D007328:Insulin
compliance; diabetes; diabetic ketoacidosis; medical intensive care unit; protocol