Objective : To treat mild and resolving DKA in a non-ICU setting aiming to increase ICU bed availability, reduce cost, increase ED throughput and evaluate the effect on length of stay and occurrence of invasive procedures.
Methods : This study- a QI/ pilot study- being conducted on the 7s unit is still in its early beginings. Inclusion criteria include patients with mild DKA admitted to the internal medicine teaching service. The teaching services consist of teams with PGY2/3 internal medicine residents and interns supervised by an internal medicine teaching faculty. Mild DKA is defined per ADA classification: pH 7.25-7.3, Bicarbonates 15-18, positive ketones, anion gap above 10 and absent altered mental status. Moderate and severe DKA along with hemodynamically unstable patients are excluded since they require ICU admission. Patients are treated with IVD insulin and labs drawn per the hospital DKA guideline.
Results : The study was started in December of 2018 and four patients have been enrolled: average age is 33 years old; three males and one female. All patients had anion gap closure within 13 hours of admission without any complications including hypoglycemia. Three of the four patients were admitted for DKA only and one patient was admitted for an acute infection with subsequent DKA. The average length of stay for the three patients admitted for primary DKA diagnosis was 1.6 days; the fourth patient had a length of stay for 12 days due to other medical workup. The average length of time to normoglycemia (defined as a glucose <180) was 7.1 hours.
Discussion : This preliminary study shows that it is safe to treat DKA outside of the ICU without an increase in complication rates, increase in morbidity and mortality. It also reduces the need for more invasive procedures including arterial lines and central lines. Furthermore, length of stay was not significantly increased as most patients were discharged in less than two days.
Conclusion : Studies have shown that it is safe and effective to treat mild DKA patients outside the ICU. Available studies have used subcutaneous insulin though. Our preliminary data shows that it is indeed safe to treat mild DKA outside the ICU with IVD insulin without increasing the rate of complications or need for escalation of care. Length of stay is reduced and resource utilization is much more efficient.. Further data collection and analysis is ongoing.
Zoya Hussain– Resident Physician, UIC/Advocate Christ Medical Center, Chicago, Illinois
Aelia Fatima M.D.– Resident Physician, UIC/Advocate Christ Medical Center, Chicago, Illinois
Joumana Chaiban– Associate Professor of Clinical Medicine; Internal Medicine Residency Program Research Director, University of Illinois at Chicago; Advocate Christ Medical Center, Department of Internal Medicine, Endocrinology Division
Tahira Yasmeen– Section Chief of Endocrinology, Advocate Christ Medical Center, Illinois
UIC/Advocate Christ Medical Center
Third year internal medicine physician who is interested in hospitalist medicine as well as quality improvement and patient safety.
UIC/Advocate Christ Medical Center
Associate Professor of Clinical Medicine; Internal Medicine Residency Program Research Director
University of Illinois at Chicago; Advocate Christ Medical Center, Department of Internal Medicine, Endocrinology Division
Dr. Chaiban is an attending endocrinologist at UIC/Advocate Christ Medical Center. She teaches UIC/ACMC internal medicine residents as well as UIC endocrinology & metabolism fellows from UIC. She also serves as the research director for the internal medicine residency at UIC/ACMC.