Diabetic Ketoacidosis:

Transcription

1 Diabetic Ketoacidosis: Qality Analysis and Improvement Northwestern Medicine Amisha Wallia MD MS Glycemic Control Committee Co-Chair, NM Smmer 2018

2 Overview Concept -> Ideation to Reality Infrastrctre Methodology Baseline Data Protocol Implementation Post Protocol Data Improvement Recommendations

3 Utilization of Infrastrctre Academy for Qality and Safety Improvement Collaboration between the Department of Medicine and the Center for Healthcare Stdies, and NM Process Improvement Application to address Diabetic Ketoacidosis Capitalized on both research, trainee, and qality infrastrctre

4 DMAIC Methodology with Formal Training Define Measre Analyze Improve Control

5 Otline for Research Methods Srveys (Nrses, NPs, Pharm, MDs) Online/Verbal Consent DKA Qality Improvement Project Srveys (Nrses, NPs, Pharm, MDs) Online/Verbal Consent Retrospective Chart Review Intervention Retrospective Chart Review At 6 month and 1 year

6 Bilding a Database: Inclsion Criteria Diabetes and DKA diagnosis code , , , E08.10, E08.11, E09.10, E09.11, E10.10, E10.11, E11.69, E13.10, E13.11 Diabetes and DKA lab criteria 250.XX, E08.xx, E09.xx, E10.xx, E11.xx, E13.xx Glcose 250 mg/dl and HOC3 18 and Arterial ph 7.32 or Venos ph 7.22 DKA Intravenos Inslin Infsion Protocol Order Set

7 Baseline Data Jan 1, Jne 30, 2013 N=310 Enconters (240 patients) Qantitative Data 70 of 310 (22.6%) DKA readmissions 25 of 240 (10.4%) patients readmitted dring stdy timeframe (other dx) Qalitative Data (provider srveys) Where do yo think improvements in care are needed?

8 Srvey Reslts

9 AQSI- DKA TREATMENT GUIDELINES Arrival Q 1 hr Q 2 hr Do not se if Cr >3, Can consider Endocrinology Conslt if GFR < 30 Monitor VS, ABG, CBC, BMP, PO4, Mg++, UA VS, I&O, Acccheck or ABG-glcose vale BMP and ABG (PRN) Q 4 hr Ca ++, PO 4, Mg ++ Electrolytes Add 40 meq KCL to IV infsion after first void and if K + < 4.5 Optional - If PO4 <2 meq/l consider a phosphate rider CRITERIA FOR ICU ADMISSION Triage with Arterial Blood Gases Admit to ICU if: (2 or > present, Physician Discretion) 1. BG>250, HCO3<10, ph<7.25 (by ABG) 2. Secondary factors: Fever Hypotension Infection Evidence of infiltration on Chest X ray Elevation of troponin level or cardiac dysfnction CKD III or worse 3. Admission time from ED 8 PM-5 AM 4. Expected IV drip dration of > 6 hors CRITERIA FOR FLOOR/ OBSERVATION ADMISSION Admit to ER Observation or Floor if: (ALL 3) 1. BG< 250, HCO3>15, ph >7.25 (by ABG) 2. Expected IV drip dration of < 6 hors 3. Admission time from ER 5 AM-8 PM On Admission Orders: Order Diabetes Edcation if Applicable INSULIN PROTOCOL TABLE 1. INITIAL INSULIN DOSE AND INFUSION RATE Blood Glcose Bicarb Inslin Bols Dose Inslin Infsion Rate IV Flid Bols >300 <18 0.1nit/kg Bols 0.1nit/kg 0.9N% NaCl 1-2 L bols IV Flid Rate per MD Orders 0.9%NaCl TABLE 2. BLOOD GLUCOSE INCREASING TITRATION TABLE (> 50 mg/dl) Crrent Glcose Bicarb Inslin Drip Titration (/hr) IV FLUIDS >250 <18 INCREASE infsion by 50% of crrent rate 0.9%NaCl <18 INCREASE infsion by 25% of crrent rate CHANGE TO: D5% 0.45%NaCl <18 NO CHANGE CONTINUE D5% 0.45%NaCl TABLE 3. BLOOD GLUCOSE DECREASING TITRATION TABLE Crrent Glcose Bicarb LESS THAN 50mg/dl BETWEEN mg/dl >250 <18 INCREASE infsion by 50% of crrent rate NO CHANGE <18 NO CHANGE DECREASE infsion by 25% of crrent rate <18 DECREASE infsion by 50% of crrent rate <18 DECREASE infsion by 75% of crrent rate Blood Glcose Decrease DECREASE infsion by 75% of crrent rate STOP INFUSION Page service for orders GREATER THAN 100mg/dl DECREASE infsion by 25% of crrent rate DECREASE infsion by 50% of crrent rate DECREASE infsion by 75% of crrent rate STOP INFUSION Page service for orders IV FLUIDS 0.9%NaCl CHANGE TO: D5% 0.45%NaCl CONTINUE D5% 0.45%NaCl CONTINUE D5% 0.45%NaCl 70 <18 STOP INFUSION, give 15 g carb PO or 25 D5% ml of 50% dextrose IV, recheck glcose q %NaCl min ntil greater than 70, then horly. Restart inslin infsion at 25% of previos rate if glcose is Restart inslin infsion at 50% of previos drip rate once glcose is greater than 150 mg/dl.

10 PROVIDER CRITERIA FOR TRANSFER FROM IV TO SUBQ: BG < 250 mg/dl, HCO3 > 18, able to take oral intake Patient transitioning to sbctaneos inslin regimen (or ICU to Floor) THE FOLLOWING OCCURS AT THE SAME TIME Convert to Sbctaneos Inslin when patient has the following: Glcose < 250mg/dl, and HCO3 >18 can start Basal/Bols Inslin per below(rn to page pharmacist to expedite Glargine administration) 1-Discontine D5/0.45% NaCl, if tolerating po 2- Give Glargine Inslin (long acting) 0.3 nits/kg OR by drip rate [50% of Total Daily Dose estimated from stable 4 hor drip rate]. If greater than 20% discrepancy between both calclations and/or from the home dose of long acting inslin, consider Endo conslt) 3- Give Lispro Inslin (bridge dose) = 10% of Glargine Dose at same time as Glargine 4- Discontine inslin drip after pt receives Glargine and Lispro bridge inslin injections AFTER 1-4 HAS BEEN DONE: Check Glcose 2 hrs after inslin drip is discontined & cover per Lispro spplemental scale Sbctaneos Inslin Regimen Gidelines Diet Acccheck Sbctaneos Inslin Regimen NPO Q 4 hrs Lispro medim dose spplemental scale if glcose >150mg/dl Eating Q AC Lispro 0.1 nit/kg (if greater than 20% discrepant from 33% glargine dose with each meal OR from the home dose of Lispro, consider Endo conslt) Lispro medim dose spplemental scale if glcose > 150mg/dl Lispro Medim Dose Spplemental Scale Glcose (mg/dl) Lispro Dose (Units)- sbctaneos Criteria for DM edcation conslt: New Diagnosis of DM (Type 1 or 2) Recrrence of DKA within 30 days Length of stay >3 days (related to glcose control) Inability to manage d/c DM home regimen Criteria for Consideration of Endocrine conslt: DM and CKD (Stage 3 or >) Need to start D10% infsion New Diagnosis of DM (Type 1) Length of stay>3 days (related to glcose control) Criteria for Discharge to Home (All criteria) -Hemodynamic and metabolic stability (bicarb > 18, K < 5.5, Mean glcose <300) -Determine diabetes knowledge, conslt DM Edcator or case management as needed (able to self-monitor glcose levels and administer inslin) -Schedle appointment with PCP or Endocrinologist in 2-4 weeks -Patient has inslin/spplies (able to obtain inslin-verification of coverage throgh pharmacy, social work vochers as needed) -Tolerating PO intake -Resoltion of any precipitating medical factor(s)

11 DKA Protocol Implementation Lanch Date: Jly 1, 2015 NM Departments Involved Emergency Department MICU Medicine Endocrinology

12 Implementation Methods Edcation Training Glcose Management Service and Certified Diabetes Edcator led training of bedside nrses with qiz (ED/Medicine) Endocrine Attending modlar lectre to resident physicians (ED/Medicine) Endocrine led seminar (Endocrine Fellows) Resorces DKA pocket card distribted to all residents IT Intervention Powerchart Order set DKA protocol available on NM Resorces page

13 Patient Poplation Baseline and Post Protocol Implementation 1/1/2010-6/30/2013 8/1/2015-2/28/2017 Baseline N=240 Post N=256 Age, median (min, max) 41.5 (19, 92) 57 (18, 91) BMI* 27.7 ± ± 10.9 Sex n (%) Male 124 (51.7) 138 (53.9) Female 116 (48.3) 118 (46.1) Race, n(%) Black or African American* 109 (45.4) 57 (22.3) Hispanic or Latino* 24 (10.0) 10 (3.9) White 103 (42.9) 128 (50.0) Other* 4 (1.7) 44 (17.2) Declined or not Reported* 0 17 (6.6) Diabetes Stats, n (%)* T1D 210 (67.7) 96 (32.5) T2D 100 (32.2) 154 (52.2) Unknown 45 (15.3) * p vale <0.01

14 Post Protocol Implementation Ag 1, 2015-Feb 28, Percentage of DKA Protocol Use Enconters N=295 Protocol Used Median 60 PROTOCOL USE (%) Ag-2015 Sep-2015 Oct-2015 Nov-2015 Dec-2015 Jan-2016 Feb-2016 Mar-2016 Apr-2016 May-2016 Jn-2016 Jl-2016 Ag-2016 Sep-2016 Oct-2016 Nov-2016 Dec-2016 Jan-2017 Feb-2017

15 Post Protocol Implementation Ag 1, 2015-Feb 28, Percentage of Protocol Use Enconters N=295 Protocol Used Mean UCL LCL 60 PROTOCOL USE (%) Ag-2015 Sep-2015 Oct-2015 Nov-2015 Dec-2015 Jan-2016 Feb-2016 Mar-2016 Apr-2016 May-2016 Jn-2016 Jl-2016 Ag-2016 Sep-2016 Oct-2016 Nov-2016 Dec-2016 Jan-2017 Feb-2017

16 Qalitative Data Front Line Provider Interviews (N=11) Knowledge, Workflow, Improvements Endocrinology (3) Medicine (1) Emergency Department (3) Management (1) Lrie Children s ED(3)

17 GO UPSTREAM: ED Specific Needs Delay in Protocol Initiation ED lab confirmation (estimated 45min-1hr) Leads to MD workaronds to initiate inslin Protocol Sggestion Tool EMR ndge for DKA protocol se connected to chief complaint

18 Diagnosis: DKA Stats Classification Classification of Protocols Clinical stats vs. location based Mild or Moderate DKA

19 Moderate or Mild DKA Defined Kitabchi, Diabetes Care 2009.

20 Protocol Used in Sicker Patients Protocol Eligible Protocol Used Protocol Eligible Protocol NOT Used Enconters Glcose* ± ± Bicarbonate* 10.8 ± ± 3.7 VBG ph 7.1 ± ± 0.1 A1c* 10.9 ± ± 2.5 *p vale <0.0001

21 Protocol not sed in mild/moderate DKA Protocol Used DKA Dx N= 97 DM Dx + Lab Criteria N= 3 Protocol NOT Used DKA Dx N= 49 DM Dx + Lab Criteria N= 146 Inpt LOS 2.9 ± ± ± ± 6.3 Glcose ± ± ± ± 89.7 Bicarbonate 13.0 ± ± ± ± 3.1 VBG ph 7.1 ± ± ± ± 0.1 A1c 9.8 ± ± ± 2.0 Endo Conslt 68 (70.0) 0 35 (71.4) 82 (56.1) CDE Conslt 49 (50.5) 1 (33.3) 19 (38.8) 10 (6.8)

22 Areas of Improvement Delay in initiation of DKA protocol Electronic prompts and easy access Frther define appropriateness of DKA protocol se

23 Potential Protocol Updates Endocrine MD Inpt Goal: Increase se of DKA protocol appropriately in those with Moderate DKA Ensre provider knowledge abot those eligible for DKA protocol Expedite labs (bicarbonate, glcose) if possible Chief Complaint à DKA 1. ED labs drawn If VBG 7.24 à draw accrate bicarbonate ASAP 2. Draw ABG If Bicarbonate vale is < 15 VBG(reminder) expedited ph bicarbonate pco2

24 Look for low hanging frit New rapid assay for Beta Hydroxybtyrate assay to help identification for those with diabetic ketoacidosis Worked towards pblication of preliminary findings

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26 Thank yo Stdents NM Qality Teresa (Derby) Pollack Joanne Prinz Jennifer Vander Weele Ming Zang Project Mentors ED Team Dr. Jane Holl Dr. Emilie Powell Dr. Kevin O Leary ICU Team Dr. Wnderink Endocrinology ICU NP service Dr. Grazia Aleppo Pharmacists Dr. Mark Molitch Internal Medicine Residency Colleen Smyrniotis, CDE, APN Dr. Aashish Didwania Glcose Management Team AQSI Dr. Vidhya Illri Ross Ewin-York Dr. Priya Vellanki Dr. Kevin O Leary Dr. Ashley Therasse Dr. Lee-Shing Chang (Resident)