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Diabetes audit states ‘suboptimal’ care for DKA

By Editor
22nd January 2016
Audits, Good practice Latest news Research

Hospital treatment for diabetic ketoacidosis (DKA) is “suboptimal”, according to audit findings which have just been published.

The National Audit of DKA Management, which has been published in the Diabetic Medicine journal, showed that 7.8 per cent of all reported DKA cases occurred in existing inpatients and only 6.1 per cent of admissions with DKA were due to newly diagnosed people with diabetes.

The survey also found that 33.7 per cent of people had experienced at least one DKA episode in the preceding year.

The aim of the audit, which was carried out in the latter half of in 2014, was to assess how DKA is managed in the UK and how the outcomes of people with the complication are mapped against accepted national guidance.

Dr Ketan Dhatariya

Dr Ketan Dhatariya led the audit

‘National guidance’

DKA is a common and significant contributor to mortality and morbidity in people with type 1 diabetes. Clinicians often find that many inpatient morbidity experienced by people with diabetes is related to DKA treatment. 

It was organised and led by Dr Ketan Dhatariya, a consultant in diabetes, endocrinology and general medicine at the Norfolk and Norwich University Hospitals NHS Foundation Trust.

Dr Dhatariya concluded: “Despite widespread adoption of national guidance, several areas of management of DKA are suboptimal, being associated with avoidable biochemical and clinical risk.”

The audit was made up of two parts. The first part was a five page form which was designed to look at the care processes of people admitted with DKA between 1 May 2014 and 30 November 2014.

Initial nurse-led observations were carried out well, but subsequent patient monitoring remained suboptimal

The second part was a one page ‘institutional’ form, which looked at what resources were available to the teams. The forms were sent to 212 UK hospitals. A total of 72 hospitals filled out the individual forms based on 283 people, and 67 returned the institutional forms.

All hospitals had an up-to-date ketoacidosis treatment pathway, with just under 80 per cent using the Joint British Diabetes Societies (JBDS) guideline and 62.5 per cent of teams also had an integrated care pathway.

However, the report said “further work needs to be done to see if there are differences in outcomes among diabetes specialist teams who use an integrated care pathway, compared with those who do not”.

Patient resolution

Diabetes UK and other diabetes organisations have previously suggested that an appropriate level of diabetes inpatient specialist nurse staffing should be one nurse per 300 beds.

However, only 49.3 per cent of teams had a diabetes inpatient specialist nurse staffing at this level. Of the remainder, mean staffing levels were 0.62 nurses per 300 beds.

Despite evidence showing that input from the diabetes specialist teams is associated with a shorter length of hospital stay, only 65.7 per cent reported that people admitted with ketoacidosis had access to a member of the team within 24 hours of admission.

The audit results also showed that the average time a patient resolution took was 18.7 hours and the median length of hospital stay was 2.6 days.

Significant adverse biochemical outcomes occurred, with 27.6 per cent of people developing hypoglycaemia and 55 per cent reported as having hypokalaemia.

Dr Dhatariya said: “Initial nurse-led observations were carried out well, but subsequent patient monitoring remained suboptimal.

“Most patients were not seen by a member of the diabetes specialist team during the first six hours, but 95 per cent were seen before discharge. A significant minority of discharge letters to primary care did not contain necessary information.”

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