(269) Treatment of Diabetic Ketoacidosis Utilizing a Nursing-Driven Intravenous Insulin Protocol

Introduction: Limited literature is available supporting the treatment of diabetic ketoacidosis (DKA) utilizing intravenous (IV) insulin outside of the intensive care unit (ICU). In 2021, a new DKA order set was created at Methodist Charlton Medical Center (MCMC). This order set allowed nurses to manage treatment of DKA with IV insulin and titratable dextrose fluid with minimal contact to providers for orders; thereby providing consistent management and preventing delays in treatment. This order set went live system-wide in 2022; however MCMC is the only Methodist Health System (MHS) hospital that treats patients with mild to moderate DKA on an intermediate care unit (IMC) rather than an ICU. This study aims to evaluate the safety and effectiveness of treating mild to moderate DKA with IV insulin on an IMC.

Methods: A multi-center retrospective analysis was conducted evaluating patient data from those treated for mild to moderate DKA in the IMC at MCMC and those treated in the ICU at other MHS institutions. The primary outcome was the number of patients who developed rebound DKA. The secondary outcomes included costs of hospital stay, hospital length of stay, time to resolution of DKA, and rates of hypoglycemia.

Results: A total of 282 patients were included (142 in each group). The primary endpoint of rebound DKA occurrence was significantly lower in the MCMC group compared to the MHS group (3.5% versus 9.9 %, respectively; p = 0.03). The median time to resolution of diabetic ketoacidosis, cost of hospital stay, and length of hospital stay did not differ between the MCMC and MHS groups. The patients in the MCMC group did have a significantly lower number of hypoglycemic events compared to the MHS group, with an average 0.18 versus 0.32 events per patient, respectively (p = 0.05).

Conclusions: This study has shown that treating mild to moderate DKA with IV insulin on an IMC is both safe and effective using a nursing-driven protocol and titratable dextrose IV fluids. The IMC unit at MCMC has had significantly less rebound DKA and less hypoglycemic events in comparison to the ICUs at other MHS sites. Implementing a protocol such as this can provide hospitals with a safe and effective option for treating mild to moderate DKA on a step-down unit, thereby reserving intensive care unit beds for critical patients.