Carolinas Research Day 2021

Evaluation of the Emergency Department Management of Children with Diabetic Ketoacidosis Alyssa DaVolio, OMS-IV; Jacob Andrews, OMS-IV; Christine Angeles, OMS-IV; Brittany Skaggs, OMS-IV; Mackenzie Dreher, OMS- IV; Ning Cheng, PhD; Hanna S. Sahhar, MD, FAAP, FACOP. Edward Via College of Osteopathic Medicine (VCOM)-Carolinas Campus. Spartanburg Regional Healthcare System (SRHS)

CLIN-1

Abstract

Results

Conclusions

The hypothesis of this study is that the management of diabetic ketoacidosis (DKA) along with time flow of admission from the emergency Department (ED) will improve after the implementation of electronic medical records (EMR). After initial workup and stabilization, patients are often transferred to the pediatric intensive care unit (PICU) for further treatment. The purpose of this study is to re-evaluate the management of DKA and time flow in the ED before and after the implementation of EMR. A retrospective chart review of 247 subjects between the ages of 0-18 years admitted to the PICU with a diagnosis of DKA and bicarbonate level <15 was conducted. The average throughput times prior to the use of EMR in the ED was used and compared to the average throughput time after the implementation of EMR. Comparing the averages between the two groups, it was found that there was a statistically significant decrease in time from admission to the ED to decision to admit to the PICU (p<0.001) after the implementation of EMR. Additionally, there was a statistically significant increase in time from the decision to admit to the PICU to transfer to the PICU (p<0.001) after the implementation of EMR. More specifically, the implementation of EMR allowed for quicker time from admission to the ED to decision to admit to the PICU. However, the time from the decision to admit to the PICU to transfer to the PICU increased after implementation of EMR.

Comparing the averages between the two groups, there was found to be a statistically significant decrease in time from the admission to the ED to decision to admit to the PICU of 1.36 hours (82 minutes) (p<0.05) after the implementation of EMR. There was a statistically significant increase in time from the decision to admit to the PICU to transfer to the PICU of 0.95 hours (57 minutes) (p<0.05) after the implementation of EMR. The results of the study showed that the implementation of EMR resulted in quicker time from admission to the ED to decision to admit to the PICU. However, the time from the decision to admit to the PICU to transfer to the PICU increased after the implementation of EMR. Overall the data showed there is some promise to having EMR to aid in this process, but further investigation is required to determine the total amount of effectiveness that EMR will serve.

Figure 1 . Sex Demographics of Study Population

Figure 2 . Age Demographics of Study Population

0 10 20 30 40 50 60 Percentage

0 10 20 30 40 50 60 70 Percentage

Male

Female

1-5yo

6-13yo 13-17yo

>17yo

0 10 20 30 40 50 60 70 80 90 100 Percentage 0 10 20 30 40 50 60 70 80 Percentage Figure 3 . Diabetes Distribution in Study Population Figure 4 . Diabetes Distribution in Study Population

Methods

The initial treatment for DKA focuses on fluid replacement with 0.9% NaCl solution at a recommended rate of 15-20 mL/kg/hr in the first hour. The International Society for Pediatric and Adolescent Diabetes guidelines suggest insulin therapy should be withheld for at least one hour after fluid replacement in order to decrease the risk of cerebral edema. Based on this institution, insulin may be started while the patient is in the ED or can be started after transfer to the PICU. Data collected included the subjects’ gender, age, race, weight, height, initial vitals at the ED admission, ED diagnosis, time from admission to ED to decision to admit to the PICU, time from decision to admit to the PICU to transfer to the PICU, fluids (0.9% NaCl) given in the ED, amount of insulin given in the ED, the route of administration (IV drip vs bolus), blood gas results collected, and blood glucose results collected. A secure, electronic excel sheet was created for data collection and used by all researchers to enter subject data. All data was combined into a master data sheet and all patient identifiers were removed. Our design was an observational retrospective chart review of 247 patients admitted to the ED at SRHS with a diagnosis of DKA between October 1 st , 2016 and April 1 st , 2020. Inclusion criteria included: diagnosis of DKA, bicarbonate level less than 15, and between the age of 0-17 years old. Primary Outcomes: • Amount of Fluids received in the ED • Amount of Insulin received in the ED • Amount of time between a patient presenting to the ED to the decision to admit to the PICU • Amount of time between the decision to admit to the PICU and transfer to the unit Secondary Outcomes: • Other diagnoses charted in the ED • Type of diabetes

References

New DKA

Recurrent DKA

T1DM

T2DM

• Benoit, S. R., Zhang, Y., Geiss, L. S., Gregg, E. W., & Albright, A. (2018). Trends in Diabetic Ketoacidosis Hospitalizations and In-Hospital Mortality — United States, 2000–2014. MMWR. Morbidity and Mortality Weekly Report , 67 (12), 362–365. https://doi.org/10.15585/mmwr.mm6712a3 • Dhatariya, K. K., & Vellanki, P. (2017). Treatment of diabetic ketoacidosis (dka)/hyperglycemic hyperosmolar state (hhs): novel advances in the management of hyperglycemic crises (uk versus usa). Current Diabetes Reports, 17(5), 33–33. https://doi.org/10.1007/s11892-017-0857-4 • Inokuchi, Ryota, et al. “Impact of a New Medical Record System for Emergency Departments Designed to Accelerate Clinical Documentation.” Medicine , vol. 94, no. 26, 2015, doi:10.1097/md.0000000000000856. • Mendez, Yamely et al. “Diabetic ketoacidosis: Treatment in the intensive care unit or general medical/surgical ward?.” World journal of diabetes vol. 8,2 (2017): 40-44. doi:10.4239/wjd.v8.i2.40 • Redondo, M. J., Libman, I., Cheng, P., Kollman, C., Tosur, M., Gal, R. L., … Clements, M. (2018). Racial/Ethnic Minority Youth With Recent-Onset Type 1 Diabetes Have Poor Prognostic Factors. Diabetes Care , 41 (5), 1017–1024. https://doi.org/10.2337/dc17-2335

Figure 5 . Throughput Time Prior to Implementation of Electronic Medical Records

Average Time from ED Admission to Decision to Admit to PICU

2.02 hours ± 1.66

Average Time from Decision to Admit to PICU to Transfer to PICU

1.15 hours ± 1.10

Figure 6 . Throughput Time After Implementation of Electronic Medical Records .

Average Time from ED Admission to Decision to Admit to PICU

0.66 hours ± 1.31

Acknowledgements

We would like to thank Dr. Hanna S. Sahhar who provided us with guidance and direction throughout this project. We would also like to thank Spartanburg Regional Healthcare System for providing us with this opportunity to conduct research. Lastly, we would like to thank Dr. Ning Cheng for aiding us in the statistical analysis of this project.

• Weight at presentation to the ED • Vital signs at presentation to the ED

Average Time from Decision to Admit to PICU to Transfer to PICU

2.10 hours ± 1.39

19

2 0 2 1 R e s e a r c h R e c o g n i t i o n D a y