medwireNews: Implementing a nursing protocol that includes point-of-care testing at triage reduces the time to diabetic ketoacidosis (DKA) diagnosis and the number of unnecessary intravenous (iv) placements in the pediatric emergency department (ED), say researchers.
As described in Pediatrics, the average time from arrival to confirmed DKA diagnosis before these changes were introduced was 86 minutes, and although 61% of the 156 patients studied ultimately did not have DKA, more than 85% of these had iv placement and fluids while awaiting laboratory test results.
After the process of implementation and evaluation, the final initiative consisted of four parts designed to speed up and standardize DKA diagnosis and management. These were: rapid capillary point-of-care testing conducted by triage nurses, for glucose, pH, and electrolyte levels, to derive a bicarbonate level; a DKA order panel; a DKA provider guideline; and a DKA nursing protocol, which enabled nurses to obtain point-of-care testing without a provider order.
This resulted in the average time to DKA diagnosis falling to 26 minutes among 627 patients admitted for suspected DKA in the post-intervention phase, with 80% of patients having their bicarbonate level determined within 30 minutes of arrival.
And among the 57% of patients who did not meet the laboratory definition of DKA (bicarbonate <18 mmol/L), only 36% had an iv placement.
“This translates to the annual prevention of 52 painful and distressing IVs at our institution,” say Shannon Baumer-Mouradian (Medical College of Wisconsin, Milwaukee, USA) and study co-authors.
They say that while previous research has looked at reducing the stress associated with iv placement, theirs “is the ﬁrst study to reduce resource use and painful procedures by more appropriately triaging which patients needed an IV.”
The team found “only a modest improvement” in the average length of stay for patients who were evaluated for DKA but then discharged, from 206 to 186 minutes.
“Our ﬁndings support the belief that [point-of-care] testing alone is not enough to improve ED [length of stay],” the researchers write.
However, when they looked at 72-hour ED return rates to ensure their interventions did not lead to premature discharge and consequent readmission, they found the opposite: the rate fell from 13% to 7% for the whole cohort.
The researchers now hope to introduce point-of-care testing to primary care, “where rapid exclusion of DKA can reduce the need for ED evaluation, leading to improved patient satisfaction, cost savings, and more appropriate use of resources.”
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