From the 2019 HVPAA National Conference
Dr. Jamie Felzer (Scripps Clinic), Ms. Doris Meehan (Scripps Clinic), Dr. Maida Soghikian (Scripps Clinic)
Diabetic Ketoacidosis (DKA) management in the hospital is complex and often challenging. Treatment involves the use of intravenous insulin, frequent monitoring of lab values and replacement of electrolytes.
Concurrent and retrospective case reviews showed under-utilization of components of the electronic medical record (EMR) DKA prefabricated orders (PF0s). Gap analysis showed that specifically the DKA potassium orders were optional, unclear, without clinical decision support, and easily bypassed by providers.
Many patients are intracellularly depleted in potassium due to urinary losses even if the serum potassium appears normal. In addition, once intravenous insulin is started there is a rapid shift of potassium out of the cells. The monitoring and replacement of electrolytes in patients with DKA should have potassium addressed and repleted before and during insulin administration. The aim of this project was to ensure potassium replacement was ordered properly and carried out on all patients with DKA.
With input from key stakeholders, we implemented countermeasures by making it mandatory to replete potassium, and stated that insulin should not be given until potassium is >3.3mmol/L. A hard stop was added for ongoing replacement, and providers could choose to replete to potassium of 3.5 (for End-Stage Renal Disease), 4 or 5 mmol/L, but must choose one of the options. Decision support was added for potassium replacement, with relevant lab values displayed, including Creatinine Clearance, potassium, serum creatinine. Lab draws and electrolyte replacement were changed to be on the same schedule.
This was initially tested in the EMR Playground and went live in one hospital for three months, prior to being rolled out to another hospital. With the assistance of the Diabetic Advance Practice Nurses- patients, providers and nurses were closely monitored for their practice patterns and understanding of the treatment. After the new protocols, only 55% of patients with DKA had their potassium repleted appropriately. Further, in those that didn’t have appropriate potassium replacement, 80% did not have a follow-up lab draw within two hours. A survey was performed in a small sample size of Intensive Care Unit (ICU) nurses and the majority stated they rarely cared for patients with DKA and one of the most difficult areas for them to navigate was the potassium replacement and subsequent lab orders. Education was given to nurses and physicians regarding utilization of the DKA PFOs.
Close monitoring of electrolytes is vital in patients with DKA. Creating an EMR potassium “Hard Stop” lab order leads to all patients with DKA having potassium replacements ordered.
However, replacement was still missed in many patients due to the timing of lab draws, unfamiliarity with the protocol by nursing and transfer of care gaps. A multidisciplinary DKA committee was formed to further address these practice issues and knowledge gaps on both nursing and physician sides. They now meet on a monthly basis and review each case of DKA, evaluating all aspects of the management to ensure each patient is receiving appropriate care. They also review the DKA order sets on a regular basis. The identification of this important management gap has spurred multiple areas of quality improvement.