Departments of Emergency Medicine,
Pediatric Endocrinology and McNeely Diabetes Center, Children's Minnesota, St Paul, Minnesota; and.
Pediatrics. 2020 Mar;145(3). doi: 10.1542/peds.2019-1104. Epub 2020 Feb 13.
Children with established type 1 diabetes (T1D) who present to the emergency department (ED) with mild diabetic ketoacidosis (DKA) are often hospitalized, although outpatient management may be appropriate. Our aim was to reduce hospitalization rates for children with established T1D presenting to our ED with mild DKA who were considered low risk for progression of illness.
We conducted a quality improvement initiative between January 1, 2012, and December 31, 2018 among children and young adults ≤21 years of age with established T1D presenting to our tertiary care ED with low-risk DKA. Children transferred to our institution were excluded. DKA severity was classified as low, medium, or high risk on the basis of laboratory and clinical criteria. Our quality improvement initiative consisted of development and implementation of an evidence-based treatment guideline after review by a multidisciplinary team. Our primary outcome was hospitalization rate, and our balancing measure was 3-day ED revisits. Statistical process control methods were used to evaluate outcome changes.
We identified 165 patients presenting with low-risk DKA. The baseline preimplementation hospitalization rate was 74% (95% confidence interval 64%-82%), and after implementation, this decreased to 55% (95% confidence interval 42%-67%) (-19%; = .011). The postimplementation hospitalization rate revealed special cause variation. One patient in the postimplementation period returned to the ED within 3 days but did not have DKA and was not hospitalized.
Hospitalization rates for children and young adults presenting to the ED with low-risk DKA can be safely reduced without an increase in ED revisits.
患有 1 型糖尿病（T1D）的儿童，若因轻度糖尿病酮症酸中毒（DKA）就诊于急诊科（ED），通常会住院治疗，尽管门诊管理可能是合适的。我们的目的是降低在我院 ED 就诊的患有轻度 DKA 且病情进展风险低的稳定 T1D 儿童的住院率。
我们于 2012 年 1 月 1 日至 2018 年 12 月 31 日，对我院就诊的患有稳定 T1D 且患有低危 DKA 的儿童和年轻成年人（≤21 岁）进行了一项质量改进活动。我们排除了转至我院的患儿。DKA 严重程度根据实验室和临床标准分为低危、中危或高危。我们的质量改进活动包括在多学科团队审查后制定和实施基于证据的治疗指南。我们的主要结果是住院率，平衡指标是 ED 3 天内复诊。采用统计过程控制方法评估结果变化。
我们共确定了 165 例患有低危 DKA 的患者。实施前的基础住院率为 74%（95%置信区间 64%-82%），实施后降低至 55%（95%置信区间 42%-67%）（-19%； =.011）。实施后的住院率显示出特殊原因的变化。在实施后的阶段，有 1 例患者在 3 天内返回 ED，但没有发生 DKA，也未住院。
在不增加 ED 复诊的情况下，可安全降低因低危 DKA 就诊 ED 的儿童和年轻成年人的住院率。
