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Cited by 39Diabetes Management and ResearchHyperglycemia and glycemic control in critically ill and hospitalized patientsDiabetes Treatment and Management

Evaluation of outcomes following hospital-wide implementation of a subcutaneous insulin protocol for diabetic ketoacidosis

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Rao, Priya, Jiang, Sheng-fang, Kipnis, Patricia, Patel, Divyesh M., Katsnelson, Svetlana, Madani, Samineh, Liu, Vincent X.·2022·JAMA Network Open
DOI 10.1001/jamanetworkopen.2022.6417PMC PMC8990349
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Abstract

Importance: Standard diabetic ketoacidosis care in the US includes intravenous insulin treatment in the intensive care unit. Subcutaneous (SQ) insulin could decrease intensive care unit need, but the data are limited. Objective: To assess outcomes after implementation of an SQ insulin protocol for treating diabetic ketoacidosis. Design, Setting, and Participants: This cohort study is a retrospective evaluation of a prospectively implemented SQ insulin protocol. The study was conducted at an integrated health care system in Northern California. Participants included hospitalized patients with diabetic ketoacidosis at 21 hospitals between January 1, 2010, and December 31, 2019. The preimplementation phase was 2010 to 2015, and the postimplementation phase was 2017 to 2019. Data analysis was performed from October 2020 to January 2022. Exposure: An SQ insulin treatment protocol for diabetic ketoacidosis. Main Outcomes and Measures: Difference-in-differences evaluation of the need for intensive care, mortality, readmission, and length of stay at a single intervention site using an SQ insulin protocol from 2017 onward compared with 20 control hospitals using standard care. Results: A total of 7989 hospitalizations for diabetic ketoacidosis occurred, with 4739 (59.3%) occurring before and 3250 (40.7%) occurring after implementation. The overall mean (SD) age was 42.3 (17.7) years, with 4137 hospitalizations (51.8%) occurring among female patients. Before implementation, SQ insulin was the first insulin used in 40 intervention (13.4%) and 651 control (14.7%) hospitalizations. After implementation, 98 hospitalizations (80.3%) received SQ insulin first at the intervention site compared with 402 hospitalizations (12.8%) at control sites. The adjusted rate ratio for intensive care unit admission was 0.43 (95% CI, 0.33-0.56) at the intervention sites, a 57% reduction compared with control sites, and was 0.50 (95% CI, 0.25-0.99) for 30-day hospital readmission, a 50% reduction. There were no significant changes in hospital length of stay and rates of death. Conclusions and Relevance: These findings suggest that a protocol based on SQ insulin for diabetic ketoacidosis treatment was associated with significant decreases in intensive care unit need and readmission, with no evidence of increases in adverse events.

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  • Individuals with mild and uncomplicated DKA can be managed with subcutaneous rapid-acting insulin doses given every 1-2 h.

    “Individuals with mild and uncomplicated DKA can be managed with subcutaneous rapid-acting insulin doses given every 1-2 h (180)”

    From 16. Diabetes Care in the Hospital: Standards of Care in Diabetes—2026 (2026) · cites this paper as [180]

    The Discussion (page not provided) says subcutaneous short-acting insulin given up to every 2 hours was safe and effective for DKA, supporting part of the claim. But the paper’s own protocol used rapid-acting lispro every 4 hours (Methods, page not provided); the copy does not establish a 1-hour dosing interval. (LLM, conf=0.87)

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Cited by

Sorted by citations

Authors
Rao, P., Jiang, S.-F., Kipnis, P., Patel, D. M., Katsnelson, S., Madani, S., & Liu, V. X.
Affiliations
  • Kaiser Permanente San Jose Medical Center (US)
  • Kaiser Permanente (US)
Corresponding author
Liu, Vincent X.
ORCID
Venue
JAMA Network Open
Publisher
American Medical Association (AMA)
Published
2022-04-07
Volume
5
Issue
4
Pages
e226417
ISSN
2574-3805 (ISSN-L)
DOI
10.1001/jamanetworkopen.2022.6417
PMC
PMC8990349
OpenAlex
W4223518513
Cited by
39
References
1
Citations by year
2026: 4 · 2025: 11 · 2024: 14 · 2023: 8 · 2022: 2
FWCI
6.49
Type
journal article
Language
en
Open access
Licence
cc-by
Locations
  • JAMA Network Open (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
Funders
  • Kaiser Permanente
  • National Institutes of Health
  • National Institute of General Medical Sciences (R35GM128672)
Topics
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Hyperglycemia and glycemic control in critically ill and hospitalized patients
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
Keywords
diabetic ketoacidosis, subcutaneous insulin, insulin protocols, intensive care unit admission, hospital readmission, length of hospital stay, mortality, diabetes management, hospital-wide implementation, quality improvement, hospitalized patients, integrated health system, 30-day readmission, diabetes self-management
MeSH terms
Adult, Diabetes Mellitus, Female, Hospitals, Humans, Insulin, Length of Stay, Retrospective Studies, Cohort Studies, Diabetic Ketoacidosis, Insulin, Regular, Human

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