Implementing Treatment Guidelines for Diabetic Ketoacidosis in the Emergency Department

Diabetic ketoacidosis is a common diabetic emergency, and treatment is usually began in the emergency department. At Intermountain Medical Center Emergency Department, there are a variety of ways that diabetic ketoacidosis treatment is approached, with no treatment guidelines currently available. Diagnosis is often delayed, and although point-of-care measurements to help guide diagnosis are available, they are rarely utilized. The objective of this project was to conduct a literature review, and using current research, construct a treatment guideline for the treatment of diabetic ketoacidosis in the emergency department. The goal of the treatment guideline is to provide nursing standing orders, expedite diagnosis, standardize treatment, and improve continuity of care between the emergency department and the intensive care unit, potentially leading to better patient outcomes. In order to expedite diagnosis and treatment, beta-hydroxybutyrate has been suggested in the treatment guideline to facilitate quicker recognition of the condition. Beta-hydroxybutyrate is specific quantitative measurement of the ketones produced in diabetic ketoacidosis, and a level >3.5 in adults can confirm diagnosis of diabetic ketoacidosis (Charles et al., 2007). Traditionally, insulin boluses have been used to initiate treatment for diabetic ketoacidosis. Recent studies and a consensus statement from the American Diabetic Association state that an insulin bolus is no longer necessary, and has not been shown to improve outcomes. A continuous intravenous regular insulin drip of 0.14 units/kg/hr has been recommended for treatment (Kitabchi et al., 2009). After a rigorous review of the literature and working with content experts, emergency department guidelines were formed. Educational materials based off of these treatment guidelines were developed and provided nursing staff education. Guidelines were presented to the emergency department medical director. Nursing education materials were presented to the emergency department nursing educator. An article regarding treatment in the emergency department was written and submitted to the Journal of Emergency Nursing. Actual implementation of these guidelines into the emergency department are in progress. Previous studies have illustrated that using a protocol for diabetic ketoacidosis in the emergency department reduces the time it takes to initiate management, thus optimizing care. It has also been recommended that each hospital have a treatment guideline to guide care for diabetic ketoacidosis (Devalia, 2010). Thus, implementing this treatment guideline will potentially expedite diagnosis and treatment, as well as improve continuity of care from the emergency department to the intensive care unit