Category: Diabetes/Prediabetes/Hypoglycemia

Rates of Rebound Hyperglycemia Using an EMR vs Manual Order Entry in Patients with DKA or HHS

Monday, Apr 8
1:00 AM – 2:00 AM

Objective :

Uncontrolled blood sugar in Type I diabetics can lead to Diabetic Ketoacidosis (DKA) while the equivalent for Type II diabetics is Hyperosmolar Hyperglycemic State (HHS).  While an effective treatment protocol for these complications exists, rebound hyperglycemia has been found to be a significant issue during treatment and is harmful to the patient’s health.  The purpose of this study is to determine the rates of rebound hyperglycemia of patients admitted for treatment to MUSC with the diagnosis of DKA or HHS and evaluating the effects of using an EPIC EMR Smart Set vs entering manual orders.

Methods : We performed a retrospective chart review to identify patients diagnosed with DKA or HHS in a one year period. The inclusion criteria included a diagnosis of DKA or HHS between 08/31/15 through 08/31/16, DKA criteria according to guidelines, HHS criteria according to guidelines, patients admitted to MUSC for inpatient treatment (intensive care unit and medical/surgical/ob-gyn floors), and adults aged 18 years old and greater. There were no exclusion criteria. We reviewed 314 charts with a diagnosis of DKA or HHS from the period of study. DKA was defined as a plasma glucose > 250 mg/dL, arterial pH < 7.30, serum bicarbonate < 18 mEq/L, presence of urine ketones, and anion gap > 10. HHS was defined as plasma glucose > 600 mg/dL, arterial pH > 7.3, serum bicarbonate > 18 mEq/L, urine ketones may or may not have been present, and anion gap may have been absent or mild. Approximately 50% of the charts were excluded because the patients did not meet the DKA or HHS diagnosis criteria.

Results : The differences between Smart Set use versus Manual Orders and the rates of rebound hyperglycemia during this period at our institution showed there were no significant differences found between the use of a Smart Set and manually inputting orders on the rates of rebound hyperglycemia. Additionally, we found there were no significant differences regarding time on intravenous (IV) insulin, length of stay, and time to anion gap closure from initiation of IV insulin.

Discussion :

Differences between smart set use vs manual orders was limited by the limited sample size of patients in the manual order set group.  Acquiring additional data from prior years may help provide more accurate data.

Conclusion : The results from this study showed that using a DKA order set vs entering orders manually did not affect the rate of rebound hyperglycemia in patients admitted with DKA or HHS. There may be greater differences seen between using a DKA order set vs entering orders manually with a larger sample size.


Kathie Hermayer

Division of Endocrinology, Diabetes & Medical Genetics, Medical University of South Carolina and Ralph H. Johnson VA Hospital.

Kathie L. Hermayer, M.D., MS, is an associate professor of medicine and endocrinology in the Division of Endocrinology, Diabetes, and Medical Genetics at the Medical University of South Carolina (MUSC), Charleston, South Carolina. She is also the director for the diabetes management service and medical director of hospital diabetes services at MUSC.
Dr. Hermayer completed a master’s degree in biochemical nutrition at the University of Connecticut, Storrs, Connecticut. After receiving her medical degree from Albany Medical College, Albany, New York, she served an internship, a residency, and a fellowship, all at MUSC. She served a two­year national public health scholarship in primary care medicine in St. George, South Carolina from 1984 to 1986. She has been on faculty at MUSC since the completion of her endocrine fellowship in 1992.
Dr. Hermayer has received grants for research on the treatment of diabetes, bone diseases and other endocrine diseases. She has written numerous articles, chapters and abstracts relating to diabetes, thyroid and other endocrine disorders.

Pamela Arnold

Manager Diabetes Programs
Medical University of South Carolina
Charleston, South Carolina

Pam Arnold, MSN, APRN, BC-ADM,CDE graduated from Kent State University with a BSN in 1975 and a MSN in 1980 with a clinical nurse specialization (CNS) in the adult patient with diabetes mellitus. Pam has over 40 years experience in diabetes care, education and research. Pam assisted in the development of 'Diabetes Centers' in Ohio, Florida, South Carolina and Oklahoma, has been the Clinical Director of the Diabetes Initiative of South Carolina for the past 24 years and is a clinical and education expert in adults with diabetes, both inpatient and outpatient. Pam coordinates MUSC Outpatient ADA Education Recognition Program (multi-site) and JC Inpatient Diabetes Advanced Certification (2011, 2013, 2015, 2017). Finally, Pam is adjunct clinical faculty in the MUSC College of Nursing.

Leonidas Walthall

Medical University of South Carolina
Charleston, South Carolina

Originally from Texas, Dr Walthall completed his schooling in that great state before moving to Charleston for residency. After graduating, he stayed aboard at the Medical University of South Carolina as faculty. His interests include interdisciplinary communication, clinical and preclinical education, and inpatient diabetes management. Outside of medicine, his interests are broad, including the mountains, Wendell Berry, and Rush.

Prashant Bhenswala

Clinical Research Fellow
Medical University of South Carolina
Charleston, South Carolina

Completed medical degree at the Medical University of South Carolina in 2017. Completed a Masters of Science in Clinical Research degree at the Medical University of South Carolina in 2017.

Shaun Nguyen

Professor and Director of Clinical Research
Medical University of South Carolina
charleston, South Carolina


Daniel Lackland

Medical University of South Carolina

Daniel T. Lackland is Professor of Epidemiology at the Medical University of South Carolina. He received his doctorate degree in cardiovascular epidemiology from the University of Pittsburgh. He is a Fellow in the American College of Epidemiology, American Society of Hypertension, and American Heart Association. He directs the Division of Translational Neuroscience and Population Studies, and the Masters of Science in Clinical Research Program. He also serves as chair of the Oversite Advisory Committee for the American Heart Association Strategically Focused Research Network on Hypertension. Dr. Lackland was appointed to the Evidence Rating Committee for the 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Much of his research interest involves the population risk assessment of cardiovascular disease, stroke and hypertension. He is the principal investigator for the NIH-funded Black Pooling Project assessing the disparities in cardiovascular diseases and hypertension, and is subcontract PI for “Impact of Nativity on Cardiometabolic Syndrome Factors” in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study.

In addition to these epidemiological investigations, Professor Lackland is involved in population high blood pressure control efforts with over 275 scientific journal publications. He is President of the World Hypertension League and serves on the boards of the Carolinas Center for Medical Excellence, Consortium for Southeastern Hypertension Control (COSEHC), and Inter-American Society of Hypertension. He is Deputy Editor-In-Chief of the Journal of Clinical Hypertension, and member of the editorial boards of Hypertension, Ethnicity and Disease, Journal of the American Society of Hypertension, and Advances in Cardiovascular Therapeutics. He also leads blood pressure and risk factor screening activities at sporting events in the Southeast, and is a consultant for high blood pressure control programs throughout the world.

Wendy Bullington

Medical University of South Carolina

Wendy Bullington, PharmD, is an internal medicine pharmacist at the Medical University of South Carolina (MUSC) in Charleston, SC. She completed her PharmD at MUSC and then completed a two-year Pharmacotherapy Specialty Residency. She is board certified in Pharmacotherapy and spends the majority of her time dedicated to direct patient care. She is very involved with the Cystic Fibrosis Foundation, serving on their Strategic Action Planning Team and the Medication Adherence Strategic Planning Committee. She is currently a Champion for the Partnerships for Sustaining Daily Care Initiative.