Prehospital Factors Associated With Illness Severity in Pediatric Diabetic Ketoacidosis

Introduction: Diabetic Ketoacidosis (DKA) is a leading cause of pediatric ICU admissions. While prior studies have focused on clinical outcomes such as length of stay, morbidity, and mortality, few have investigated the association between pre-hospital sociodemographic and structural factors on illness severity at PICU presentation. We hypothesized that pre-hospital factors – including race, referral source, diabetes diagnosis status (new vs known), and neighborhood-level indices (Child Opportunity Index [COI] – are associated with worse biochemical derangements at PICU admission, including lower bicarbonate, higher anion gap, higher glucose, and elevated hemoglobin A1c (Hgb A1c).


Methods: This retrospective cohort study included pediatric patients (age 0-18 years) admitted to the Riley Children’s Hospital PICU from 2018-2024 with an ICD-10 diagnosis of T1DM and DKA. Admission laboratory data – including anion gap, bicarbonate, glucose, and Hb A1c – were collected and used as markers of illness severity. These values were analyzed in relation to pre-hospital factors: age, gender, race, diagnosis status (new vs known Type 1 Diabetes Mellitus [T1DM]), referral source (direct ED vs outside hospital (OSH) transfer), and neighborhood metrics (COI) using linear regression.


Results: In total, 786 encounters met study inclusion criteria. Black race (β=75; p< 0.01), OSH transfer (β=68; p< 0.01), higher COI (β=1.3; p< 0.01), and new DM1 diagnosis (β=67; p< 0.01) were all associated with increased presenting glucose levels. Increasing age (β=0.15; p< 0.01), Black race (β=0.7; p=0.01), and new DM1 diagnosis (β=1.7; p< 0.01) were associated with higher initial Hgb A1c levels. Male sex (β=1.4; p=0.01) was associated with higher presenting anion gap, while new DM1 diagnosis (β= -1.4; p=0.03) was associated with lower presenting anion gap.


Conclusions: Black race, COI, older age, new onset T1DM, and OSH transfer emerged as predictors of more severe biochemical derangements. These findings underscore the need for improved early recognition, timely transfer protocols, and equitable outpatient access aimed at mitigating disparities before ICU-level care becomes necessary.