Introduction:

Diabetic ketoacidosis (DKA) is life-threatening acute complication of diabetes.
This was a re-audit of initial audit for in-patient management of DKA performed in year 2012. Following the initial audit, the revised DKA protocol was published in August 2014.

Objectives:

1. Review level of adherence to statewide DKA management protocol
2. Review management of DKA compared to current evidence available

Method:

This was a retrospective audit looking at DKA presentations from September 2014 to February 2015. The data was collected and analyzed by reviewing electronic records.

Results:

A total of 32 presentations were observed in 27 patients.

No in-hospital mortality observed. However, 22% required intensive care admission.

In 78% a previous history of DKA was identified. The mean HbA1c prior to presentation was 11.75%. Precipitating cause was identified in 84% with non –compliance or omission of insulin being the predominant cause (40%).

Serum ketones were checked in only 22% at the time of admission. Frequency of biochemical monitoring was inadequate in 37.5%. Four hourly serum ketone monitoring was done in 62.5%.

Inadequate initial fluid resuscitation was noted in 31.25% and hypokalemia observed in 37.5%. In 84% intravenous insulin was commenced within 2 hours (Median time of 90 minutes).

In 16% intravenous insulin was changed to subcutaneous regime prior to clearance of acidosis and ketonemia. Adequate cross-over between intravenous and subcutaneous insulin was done in 56% of cases. In 56% acidosis had resolved within 12 hours.

Only 47% received DVT prophylaxis.

69% were reviewed by an endocrinologist. Diabetes educator and dietician review conducted in only 31% respectively. Ongoing endocrinology follow up organized in 87% of cases.
DKA management pathway was followed in 22% in ED and 16% on medical wards. The protocol used was from year 2011.

Conclusions:

1. Inadequate biochemical monitoring and hypokalemia are ongoing issues.
2. Education, easy accessibility and adherence to state-wide guidelines have to be strongly encouraged.
3. Non-compliance was identified as a common precipitant. A previous episode of DKA is a risk factor for future recurrence.
4. Involvement of endocrinology team to improve compliance and education for sick day management plan remains of paramount importance.