From the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine.
LifeLine Critical Care Transport, Indiana University Health.
Pediatr Emerg Care. 2024 Nov 1;40(11):e265-e269. doi: 10.1097/PEC.0000000000001494. Epub 2018 Apr 24.
Diabetic ketoacidosis (DKA) is a common presentation to an emergency department (ED), with the majority presenting to community EDs. Adherence to clinical guidelines in these EDs can reduce morbidity and mortality. Few methods to describe practice gaps for DKA management have been reported.
We hypothesized that high-fidelity in situ simulation can be used to measure and compare the quality of the care provided to pediatric patients with DKA presenting to community EDs in the state of Indiana.
This observational study examined multiprofessional teams caring for a simulated pediatric patient who presented with DKA to community EDs. The primary outcome was overall adherence to pediatric DKA guidelines as measured by a validated performance checklist. A composite adherence score (CAS) was calculated using the sum of 9 checklist performance parameters. Multivariable logistic regression was used to examine the impact of ED volume and characteristics on the scores.
A 49 multiprofessional teams from 13 sites were enrolled. Of the 252 participants, 26 (10.3%) were physicians, 143 (56.7%) registered nurses, 25 (9.9%) respiratory therapists, and 58 (23.0%) were other. The overall CAS for all sites was 55.6% (25th, 75th interquartile range, 44.4%, 66.7%). Excessive intravenous fluid boluses were given by 53.1%, whereas 30.6% and 26.5% incorrectly administered insulin and sodium bicarbonate boluses, respectively. Only 10.2% used an appropriate intravenous fluid rate, and 57.1% performed an hourly glucose. No significant difference in the CAS was found due to pediatric ED volume or presence of an inpatient pediatric service.
Using validated in situ simulation; we revealed high variability in adherence to the pediatric DKA management guidelines at a wide range of community EDs. A statewide education initiative focused on decreasing variation and improving adherence to pediatric DKA guidelines is necessary for patient safety.
糖尿病酮症酸中毒（DKA）是急诊科（ED）常见的就诊病症，大多数患者在社区 ED 就诊。在这些 ED 中遵循临床指南可以降低发病率和死亡率。目前报道的用于描述 DKA 管理实践差距的方法很少。
我们假设高保真度现场模拟可用于衡量和比较印第安纳州社区 ED 就诊的儿科 DKA 患者的护理质量。
这项观察性研究检查了多专业团队对社区 ED 就诊的患有 DKA 的模拟儿科患者的护理情况。主要结局是通过经过验证的绩效检查表衡量对儿科 DKA 指南的总体依从性。使用 9 个检查表性能参数的总和计算综合依从性评分（CAS）。多变量逻辑回归用于检查 ED 量和特征对评分的影响。
来自 13 个地点的 49 个多专业团队入组。252 名参与者中，26 名（10.3%）为医师，143 名（56.7%）为注册护士，25 名（9.9%）为呼吸治疗师，58 名（23.0%）为其他人员。所有站点的总体 CAS 为 55.6%（25 分位数，75 分位数四分位距，44.4%，66.7%）。53.1%的患者给予了过多的静脉输液，而分别有 30.6%和 26.5%的患者错误地给予了胰岛素和碳酸氢钠输液。仅 10.2%使用了适当的静脉输液率，57.1%的患者每小时监测一次血糖。由于儿科 ED 量或是否有住院儿科服务，CAS 没有明显差异。
使用经过验证的现场模拟，我们发现，在范围广泛的社区 ED 中，对儿科 DKA 管理指南的依从性存在高度差异。为了患者安全，需要开展全州范围的教育活动，重点是减少变异并提高对儿科 DKA 指南的依从性。
