To improve the management of diabetic ketoacidosis (DKA) and develop condition-specific key performance indicators for long-term monitoring of quality of care, this work focused on time-to-resolution of DKA. Adopting this focus and then initiating changes to achieve it led to a reduction of resolution time of DKA on average from 22 hours to 7.4 hours, which translated into savings of over £32,000 per year for the Trust and could have a still wider impact if rolled-out on a national scale.
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We adopted the plan-do-study-act (PDSA) cycle to introduce innovative interventions to reduce the length of time patients are in DKA in our Quality improvement project. We do not know of any published quality improvement initiatives leading to a sustained reduction in time to resolution of DKA after conducting a thorough literature search on Pubmed/Medline. We have been able to demonstrate an improvement in the quality of care in patients of our Trust by identifying a novel key outcome indicator, time to resolution of DKA. We propose this to be included as one of the standards to be monitored in National Inpatient Diabetes Audit to benchmark various Trusts delivering acute care, as this will not only improve care processes for delivery of acute diabetes care but also will lead to significant savings in the NHS.
The Quality Improvement Project was undertaken at a large university tertiary care Foundation Trust in the West Midlands, United Kingdom from April 2014 to September 2016. The study was divided into five distinct periods: pre-intervention (April 2014 to September 2014), intervention (October 2014 to March 2015), early-follow-up (April 2015 to September 2015), intermediate follow-up (October 2015 to March 2015) and late follow-up (April 2016 to September 2016). All patients diagnosed with DKA according to the national guidelines during this period were included. We initially conducted an audit assessing DKA management by retrospective medical record analysis at our institution between April 2014 and September 2014. The results were presented to frontline staff involved in the management of DKA (Emergency Medicine, Acute Medicine and the Diabetes teams). Following discussion, five clinical indicators (primary drivers) were chosen for adherence to guideline recommendations to achieve reduction in time to resolution of DKA, our main outcome of interest. These were:
- Fluid replacement: Adequate fluid replacement.
- Fixed rate insulin infusion (FRII): Use of FRIII.
- Glucose measurement: Hourly glucose measurement.
- Ketone measurement: Hourly ketone measurement.
- Specialist referral: For all patients admitted with DKA to Diabetes team.
A 50% reduction in duration of DKA was the primary aim. We collected data for patient demographics, aetiology of the DKA and the aforementioned parameters during the first 12 hours following the diagnosis of DKA.
259 episodes of DKA were included in the project. Through our quality improvement interventions, we could achieve our primary goal of reducing the time to resolution of DKA. We could sustain this improvement over the 18 months’ period when we carried out this initial project and have set up a system whereby this can be easily monitored without the need for tedious audits at regular intervals. We were also successful in other secondary aims such as maintaining an increased improvement in adherence of guidelines suggesting FRIII use. We could identify an improving trend for the adherence of guidelines with regards to glucose and ketone measurements, however this was not statistically significant. Adopting the ‘time to resolution of DKA’ as the standard to focus and initiating changes to attempt to reduce this time led to savings of over £32,000 per year for our Trust. Achieving similar reduction in resolution time of DKA would therefore translate to over £5 million estimated savings for the wider NHS in England and Wales.
Sustainability and Spread
We identified a key indicator of performance of this common acute diabetes-related complication. Focusing on this indicator we had been able to drive improvement in quality of care. The overall improvement is expected to be sustained through some permanent enhancements in the system; by identifying key performance indicator of DKA management along with other existing diabetes indicators and keeping these under close monitoring; through a plan of sustained contextual learning in the organisation; and regular scheduled review of quality of care by specialist teams at ward level. We believe that the adoption of the standard ‘time to resolution of DKA’ has led to improvement in care and this should similarly be possible elsewhere should this standard be focused upon to drive improvement. We needed to make multiple systems’ management to achieve this goal. Other centres will similarly have their unique challenges and opportunities which they may need to address to achieve this goal but maintaining focus on this standard will lead to reproducible improvements in standards of care.
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