Implementation of a Two-Phase Nurse-Driven Diabetic Ketoacidosis Protocol

Introduction: Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes, characterized by hyperglycemia, metabolic acidosis, and ketosis. It commonly results from insulin deficiency but can also be triggered by infection, starvation, or acute illness. While the American Diabetes Association guidelines emphasize rehydration, glycemic control, and electrolyte management, they do not provide a standardized protocol, leaving institutions to develop their own.
Our institution recently implemented a revised two-phase DKA protocol. Phase 1 includes a titratable insulin drip with a fixed-rate fluid infusion until blood glucose falls below 250 mg/dL. Phase 2 then shifts to a fixed-rate insulin drip with a titratable fluid infusion. The comparator arm consisted of patients managed at our associated institution using a provider-driven DKA protocol. This protocol required bedside nurses to report blood glucose levels to a provider every hour, prompting manual adjustments to insulin and fluid rates.


Methods: This retrospective, two-center, single-health system study compared the efficacy of a two-phase, nurse-driven DKA protocol at one site versus a provider-driven protocol at the other. The primary outcome was time to resolution of anion gap metabolic acidosis. As per our current standard practice, time to second anion gap closure was used as the endpoint and analyzed using a Mann-Whitney U test. Artificial intelligence tools were utilized to assist with language refinement and clarity during the abstract writing process.


Results: The study compared the 43 patients treated with the two-phase DKA protocol at one site to 75 patients managed with the provider-driven protocol at the other. Time to second anion gap closure was significantly shorter in the two-phase, nurse-driven group compared to the provider-driven group (19.5 vs. 25.1 hours, P = 0.01). The two-phase protocol was also associated with shorter ICU and hospital length of stay, as well as fewer hypoglycemia events and hypokalemia events.


Conclusions: The two-phase, nurse-driven DKA protocol significantly reduced time to second anion gap closure compared to the provider-driven approach. This was associated with a decreased length of stay and fewer safety events. A standardized, nurse-driven protocol may improve efficiency and patient outcomes.