• Nursing
• Diabetes Mellitus
• Diabetes & Endocrinology Clinical Trials Diabetes & Metabolic Syndrome

• Nursing
• Diabetes Mellitus
• Diabetes & Endocrinology Clinical Trials
• Endocrinology
• Diabetes & Metabolic Syndrome

Maria Koen, NP, and Marianne Chojnicki, MHA, RN, both of the Joslin Diabetes Center, Boston, Massachusetts, USA, presented results from a pilot study of the Emergency Variable Approach and Diabetes Education [EVADE] protocol, demonstrating its effectiveness for increasing discharge rates from the emergency department (ED) and reducing admissions to the intensive care unit (ICU) associated with diabetic ketoacidosis (DKA).

Although a preventable complication, 4.6 to 8 episodes of DKA arise per 1000 patients with type 1 diabetes mellitus [Kitabchi AE et al. Diabetes Care 2001] with an associated mortality rate as high as 5% in the elderly and in patients with concomitant life-threatening illnesses and up to 2% in developing countries [Kitabchi AE et al. Diabetes Care 2009]. DKA is also responsible for > 500,000 hospital days per year, with an estimated annual direct medical expense and indirect cost of $2.4 billion that imposes a significant economic burden on the health care system.

According to the presenters, the majority of patients with DKA who present to the ED at their teaching hospital are hospitalized, and most are admitted to the ICU. However, there are no known protocols for the treatment of mild episodes of DKA in the ED to avoid hospitalization and no studies describing outcomes measures for patients with DKA who are discharged from the ED.

With this in mind, the presenters developed the EVADE protocol, a program that trains health care professionals in the ED to manage mild cases of DKA and discharge patients within 24 hours of receiving customized diabetes education to prevent DKA recurrence. One aim of the program was to reduce hospitalizations by 10% in an effort to reduce medical cost.

To assess the effectiveness of the EVADE protocol, patients who presented to the ED with blood glucose (BG) levels >300 mg/dL and bicarbonate levels ≤ 20 mEq/L were initially identified and then enrolled in the program if their condition was caused by DKA and they consented to be involved.

For all patients, the protocol involves initial intravenous (IV) fluid administration. IV insulin therapy is instituted only if laboratory results confirm DKA, with the aim of achieving a bicarbonate level of 21 mEq/L. Patients receive a starting rate of insulin based on a BG reading from an initial finger stick, with no initial insulin bolus.

If a patient requires admission to the ICU, he or she receives frequent monitoring of BG, electrolytes, venous blood gas, and urine output. Other components of the protocol include hourly finger sticks to facilitate insulin dose adjustment to achieve a target BG level of 100 to 180 mg/dL and electrolyte repletion as necessary.

Outcomes data showed that of 106 patients managed according to the protocol, 24 (23%) were discharged from the ED after a mean duration of 20 hours. Of the remaining patients who were hospitalized, the mean length of stay for those (n = 23) with non-ICU admissions was 136 hours, whereas those with ICU admissions (n = 59) had a mean length of stay in the ICU of 33 hours, followed by 77 hours in the hospital after discharge from the ICU.

These results indicate that mild DKA can be optimally managed in the ED by identifying the triggering factor, stabilizing BG and electrolyte imbalances, educating patients, and conducting a close follow-up examination. The presenters concluded that this could allow more patients to be discharged from the ED.

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