B1.2: Comparing Outcomes in Patients Admitted with Diabetic Ketoacidosis Using a Standardized Order-set Versus Individual Practitioner Orders

Carly Yim, Howard Li, Terra Arnason

Diabetic ketoacidosis (DKA) is a hyperglycemic emergency occurring in diabetics due to insulin deficiency. This results in urinary losses of water and electrolytes (sodium, potassium, chloride) and ultimately extracellular fluid volume depletion. Hallmark features of DKA include ketoacidosis, arterial pH  7.3, bicarbonate  15 mmol/L and an anion gap of >12 mmol/L. The 2018 Diabetes Canada (DC) guidelines outline the key management goals of DKA to include fluid resuscitation, resolution of ketoacidosis, correction of electrolytes and hyperglycemia as well as management of precipitating factors. It provides a detailed algorithm identifying three pillars to DKA treatment: IV fluids, serum potassium and acidosis. A 2016 DKA outcome audit at the Royal University Hospital (RUH) in Saskatoon identified that practitioners diverged considerably from (2013) Canadian Diabetes Association guidelines. Subsequently, two standardized preprinted DKA order sets were developed incorporating the 2018 DC recommendations for DKA initial and maintenance management. These order-sets were initially implemented at RUH in November 2018 and subsequently adopted by practitioners at St. Paul’s Hospital (SPH). To ensure the order-sets are promoting improved outcomes and adhering to best practices, a retrospective chart review was conducted of all adult DKA admissions at RUH and SPH from Nov. 13, 2018 to December 31, 2020. In total, 279 hospital admissions were reviewed: 99 used practitioners’ own orders, 115 used both initial and maintenance order-sets, 26 used only the initial order-set and 38 used only the maintenance order-set. Preliminary review has demonstrated that use of the initial order-set consistently meets outcomes for proper insulin dose and timing, fluid resuscitation, potassium replacement and glucose replacement. Formal data analysis is ongoing to determine whether use of the maintenance order-set ensured permanent anion gap closure upon IV insulin discontinuation and ultimately if implementation of the DKA order-sets demonstrate improved outcomes with respect to the 2018 DC guidelines.
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