A Close look at the MMC DKA Protocol

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A Close look at the MMC DKA Protocol

• Clinician driven performance improvement

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Designing a hospital-wide clinical improvement
project

• Define sources of data
• Develop quality measures
• Data reporting
• Implement changes
• Monitor results

• Identify the opportunity
• Establish the team
• Set specific goals
• Literature review
• Develop local practice guidelines

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Short Version

• Team of experts
• Literature search
• Define current process
• Identify gaps
• Develop solutions
• Establish measures
• Implement changes
• Monitor results

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Identify the opportunity

• Clinical Pathways top 25 DRGs
• Facilitated Evidence Based care
• Required critical self assessment and analysis
• Reduced variations in practice
• Offered basic performance improvement

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Establish the team

• Physician experts
• Endocrinologist
• Emergency medicine
• Internal and Family Medicine
• Performance Improvement
• Project Manager
• Data Analyst

• Nursing experts
• Diabetes Clinical Nurse Specialist
• Medical unit
• Special Care Unit
• Emergency department
• Nurse analyst
• Nutrition Services

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Set specific goals

• Decrease LOS for patients with diabetes
• Dr. Phil approach to problem solving
• cant fix what you dont acknowledge
• We did not know what we were trying to fix

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Goal Settingdont wait for the home run, just
get to first base

• Literature review
• Evidence based guidelines
• Standards of care
• Define current processes
• Identify gaps
• Identifies opportunities for improvements
• Go after low hanging fruit

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Literature review

• Hyperglycemic crisis in patients with diabetes
  mellitus
• Effect of Physician specialty on outcomes in
  diabetic ketoacidosis
• Using a severity of illness scoring system to
  access intensive care unit admissions for
  diabetic ketoacidosis
• Venous vs. arterial blood gas in assessing pH

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Summary of findings

• ADA published clinical practice guidelines
• pH is an important diagnostic tool
• Potassium should be assessed prior to insulin
• Endocrinologists are valuable in complex DKA
• Severity of illness score improves resource
  utilization
• Nutritional consults are a JCAHO standard

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Develop local practice guidelines

• Identify variations / gaps in current processes
• Flowchart reality
• Flowchart best practice 80 rule
• Brainstorm opportunities for improvement
• Let go of sacred cows
• Ask why do we do it this way
• Involve other experts to help identify solutions
• Ask what would it look like if..

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EBM

• Insulin dosing protocol
• pH is important diagnostic tool
• Obtain potassium results before insulin
• Consult endocrinologist for complex cases
• Calculations for a Severity of Illness Score
• Nutritional consult is a standard

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Gaps

• Our process
• Arterial blood gases not standard
• WHY?
• difficult to draw
• patient dissatisfier - painful
• time consuming to obtain requires RRT
• Insulin dosing before serum K results
• WHY?
• knee jerk response
• lab takes too long to turn around results 1
  hour
• lab expert time limitations inherent in running
  serum-based labs
• time to draw (tube does not always get to lab
  quickly)
• time to clot
• time to spin

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Brainstorming

• Venous blood gas is an acceptable alternative to
  ABG for the majority of DKA patients
• Point of care testing
• Venous pH, Glucose, Electrolytes
• iSTAT analyzer used in NICU for rapid results
• Standby machine for neonatal transports
• could we move it to the emergency room?

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Solutions

• Identified Chiron analyzer in lab for whole
  blood
• Venous pH
• Electrolytes
• Glucose
• Hct
• Ionized calcium
• Developed new lab item
• DKA panel
• Whole blood sample routine phlebotomy
• no time to clot
• no time to spin
• 5 min turn around time after arrival in lab
• Developed DKA Calculator

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Define sources of data

• Chart audit
• Data collection forms
• ADT data
• Electronic order entry data

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Develop quality measures

• Total admits
• SCU admits
• ED treat and DC
• Utilization of rescue drugs
• Mannitol
• Glucagon
• D50
• NaHCo3

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Data Reporting

• Select a sample of cases for review
• Develop practice and outcomes reports
• Develop ongoing monitoring program

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Implement changes in clinical practices

• Use of venous sample for pH
• Obtain potassium results before insulin
• DKA panel whole blood testing for pH, K, and
  glucose
• Insulin dosing and weaning protocol
• Consult endocrinologist for complex cases
• Calculations for a Severity of Illness Score
• Nutritional consult is a standard

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Monitor Results

• Develop ongoing monitoring program
• Team responsible to analyze data
• Revise plan as data indicates

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Clinical performance improvement is a
continuous process that does not have an end point
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