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DIABETICMedicine
DOI: 10.1111/j.1464-5491.2007.02102.x
Abstract
Metabolic Unit, Western General Hospital,
Edinburgh, UK
Accepted 21 November 2006
Aims Integrated Care Pathways (ICPs) are management plans that indicate the
sequence and timing of the optimal treatment for individuals with a given disorder.
The treatment of diabetic ketoacidosis (DKA) before and after the implementation
of an ICP in a teaching hospital was examined.
Methods Twenty-seven episodes of DKA were identified during the 13-month
Abbreviations
Introduction
The 1999 British Diabetic Association Cohort Study reported
that metabolic disturbances were the most common cause of
death in people with Type 1 diabetes under the age of 20 years
[1]. Of the deaths due to diabetes, 54% of males and 76% of
females died from diabetic ketoacidosis (DKA). There are multiple
mechanisms by which DKA can cause serious morbidity and
death, including cerebral oedema, cardiovascular insufficiency
secondary to volume depletion and acidosis, renal failure and
aspiration pneumonia [2]. Some of these deaths might be
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An Integrated Care Pathway for the management of diabetic ketoacidosis S. L. Waller et al.
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Results
In the control group, 48 episodes of DKA were identified. Of
these, only 27 episodes met the strict criteria for DKA. These
episodes occurred in 22 individuals, as one person presented
on four occasions in DKA, and two presented twice. Of those
excluded, 13 had a degree of hyperglycaemia, but the hydrogen
ion concentration and/or bicarbonate concentration did not
meet the necessary criteria. Three others had a metabolic acidosis
secondary to other causes. One was incorrectly coded (did not
have diabetes) and four sets of notes could not be retrieved.
In the ICP group, 50 episodes were identified. Of these,
24 episodes met the biochemical criteria for entry into the
study, these episodes occurred in 21 individuals, as one patient
presented on four occasions. Two patients were excluded as
the ICP was not used. One of these was human immunodeficiency virus (HIV) positive and was therefore immediately
admitted to the Infectious Diseases Unit, bypassing acute medicine; there was no obvious reason why the other patient was
not treated according to the ICP. A further 21 episodes had a
degree of hyperglycaemia, but did not meet the necessary
hydrogen and or bicarbonate criteria. Five sets of notes could
not be retrieved.
Original article
DIABETICMedicine
Age (years)
Sex (% male)
Duration of Type 1 diabetes (years)
Known previous episode(s) of DKA (%)
Plasma glucose (mmol/l)
Arterial H+ (nmol/l)
Arterial pH
Standard bicarbonate (mmol/l)
Plasma potassium (mmol/l)
Plasma creatinine (mol/l)
Plasma urea (mmol/l)
Urea : creatinine ratio
Control group
ICP group
P-value
37.0 (1460)
48.2
9.1 6.3
51.9
38.8 15.4
65.0 (51115)
7.1 0.1
9.6 3.6
5.6 0.9
126 (73690)
8.2 (3.418.6)
70.0 24.5
27.0 (1658)
54.6
8.1 6.5
36.4
33.9 14.3
61.0 (5096)
7.2 0.1
10.6 3.5
5.3 0.8
92 (4993)
6.3 (2.517.8)
70.3 23.0
0.42
0.66
0.59
0.28
0.17
0.05*
0.02*
0.06
0.29
0.18
0.23
0.96
*P < 0.05.
Parametric data are mean SD; non-parametric data are median (range).
DKA, diabetic ketoacidosis; ICP, Integrated Care Pathway.
Control group
ICP group
P-value
45.0 (5225)
60.0 (5755)
7762 1965
100.0 (20340)
6.0 (49)
37.5
48.0
69.2
59.3
48.2
3.0 (3.87.2)
3.7
22.2
37.5 (0135)
37.5 (0175)
7044 1449
80.0 (20140)
5.0 (38)
63.6
77.3
80.1
4.6
18.2
2.0 (16)
0.0
13.6
0.01*
0.01*
0.28
0.06
0.80
0.08
0.04*
0.36
< 0.001**
0.03*
0.68
0.36
0.44
Background characteristics
Outcome measures
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An Integrated Care Pathway for the management of diabetic ketoacidosis S. L. Waller et al.
Discussion
The present study demonstrated a significant reduction in the
time taken to initiate both i.v. fluids and insulin following the
implementation of the ICP. There is a paucity of randomized
trial evidence in virtually every aspect of the management of
DKA, so it is not possible to cite robust evidence that early
recourse to institution of i.v. fluids and insulin materially
affects patient outcomes. However, good clinical practice
would dictate that delay in the initiation of such therapy in
individuals who are dehydrated and acidotic should be minimized. It would seem logical, therefore, that timely initiation
of treatment would lead to a reduction in complications and
reduce recovery time in a larger group of patients.
There was also a signification reduction in both the use of
antibiotics and low molecular weight heparin between the
control and ICP periods. With regard to antibiotic treatment,
our hospital guidelines for the management of DKA stated that
patients should only be treated with antibiotics if infection is
proven or strongly suspected; this was highlighted in the ICP.
The majority of patients prescribed antibiotics in the control
group had no signs of infection documented. Local guidelines
for the prescription of low molecular weight heparin for prophylaxis of thromboembolic disease recommended prescription
in cases of diabetic coma and where prolonged bed rest was
likely. It appears that, by compelling doctors to consider
actively the indication for antibiotics and heparin, the ICP
significantly reduced overmedication of patients in these areas.
The cost savings for our cohort were not substantial (we would
estimate in the order of 134), but clearly if these findings were
replicated in a larger cohort of patients, substantial financial
savings could accrue.
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Competing interests
None declared.
Acknowledgements
Original article
DIABETICMedicine
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