Discussion
DKA is a medical emergency and prompt recognition and treatment is essential to providing good quality care. Nevertheless the findings of this series of audits are consistent with other published data and clearly illustrate that significant barriers remain in ensuring the prompt treatment of DKA. Prompt treatment of other medical emergencies have also faced similar difficulties. A national audit of adherence to a target of patients with neutropenic sepsis receiving intravenous antibiotics within 60 minutes of attendance to the emergency department showed that just 26% of patients received antibiotics within the target time, with some patients experiencing delays of over five hours.
Following the results of the audit in 2008, which illustrated poor adherence to local guidelines with only 58.6% patients meeting the 60 minute target, the diabetes team at the Whittington initiated yearly education sessions for junior staff and introduced an easily accessible guideline. This included a single sheet protocol that should be printed and placed in the patient's notes and which includes a table within which to write blood results for ongoing management, to improve continuity of care within the hospital shift systems and at handover meetings (Table 5).
The results of this series of audits shows that there have been considerable variation in the number of patients that receive intravenous fluids within the target time, with 45.8% of patients meeting the target in 2009, but 74.1% of patients receiving fluid within the recommended time in 2011. There has been overall improvement since introduction of a local guideline; with the most recent audit from 2011 having the highest yet proportion of cases meeting the target. Further research must be done to establish whether certain patient characteristics, such as having previously undiagnosed diabetes, place them at a greater risk of having delayed initiation of fluids. It would also be useful to do further investigation to ascertain which staff factors, for example seniority and experience of the admitting team, influence the delay in initiation of DKA treatment.
The acute initial phase of DKA is mostly managed by acute medical and emergency staff. The rapid changeover of these teams means that ongoing training and repeat sessions to introduce staff to the DKA guidelines and targets for treatment are essential if the proportion of cases receiving treatment is to be improved upon. Further research and audit will need to be carried out once capillary ketone testing is introduced in order to establish if this functions as an aid to a quicker diagnosis.