SQuID (subcutaneous insulin in diabetic ketoacidosis) II: Clinical and operational effectiveness.

IF 3.4 3区医学 Q1 EMERGENCY MEDICINE Academic Emergency Medicine Pub Date : 2024-09-23 DOI:10.1111/acem.15020

Richard T Griffey, Ryan M Schneider, Margo Girardi, Gina LaRossa, Julianne Yeary, Michael Lehmkuhl, Laura Frawley, Rachel Ancona, Taylor Kaser, Dan Suarez, Paulina Cruz-Bravo

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Abstract

Objective: We previously demonstrated safe treatment of low- to moderate-severity (LTM) diabetic ketoacidosis (DKA) using the SQuID protocol (subcutaneous insulin in DKA) in a non-intensive care unit (ICU) observation setting, with decreased emergency department length of stay (EDLOS). Here, we expand eligibility to include sicker patients and admission to a regular medical floor and collected more detailed clinical data in a near-real-time fashion.

Methods: This is a real-world, prospective, observational cohort study in an urban academic hospital (March 4, 2023-March 4, 2024). LTM DKA patients were treated with IV insulin (floor or ICU) or on SQuID. We compare fidelity (time to glargine and dextrose-containing fluids), safety (rescue dextrose for hypoglycemia), effectiveness (time to anion gap closure, time on protocol), and operational efficiency (time to bed request, EDLOS, and ICU admission rate since implementation of the protocol).

Results: Of 84 patients with LTM DKA, 62 (74%) of were treated with SQuID and 22 (26%) with IV insulin. Fidelity was high in both groups. Rescue dextrose was required in five (8%) versus four (18%) patients, respectively (difference 9%, -31% to 10%). Compared to the IV insulin group, time to anion gap was 1.4 h shorter (95% CI -3.4 to 0.2 h) and time on protocol was 10.4 h shorter (95% CI -22.3 to -5.0 h) in SQuID patients. Median EDLOS was lower in the SQuID cohort 9.8 h (IQR 6.0-13.6) than the IV floor cohort 18.3 h (IQR 13.4-22.0 h), but longer than the overall IV insulin cohort. Since inception of SQuID, ICU admission rate in LTM DKA has decreased from 54% to under 21%.

Conclusions: In this single-center study, we observed excellent fidelity, equivalent or superior safety, and clinical and operational effectiveness with SQuID compared to IV insulin. The SQuID protocol has become the de facto default pathway for treatment of LTM DKA. Since inception of SQuID, ICU admissions in LTM DKA have decreased 33%.

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SQuID（糖尿病酮症酸中毒皮下注射胰岛素）II：临床和运行效果。

目的：我们曾证实，在非重症监护室（ICU）观察环境中使用 SQuID 方案（DKA 患者皮下注射胰岛素）可安全治疗中低度（LTM）糖尿病酮症酸中毒（DKA），并缩短急诊科住院时间（EDLOS）。在此，我们扩大了研究对象的范围，将病情较重的患者纳入其中，并将其纳入常规医疗楼层，以近实时的方式收集更详细的临床数据：这是一项在城市学术医院进行的真实世界、前瞻性、观察性队列研究（2023 年 3 月 4 日至 2024 年 3 月 4 日）。LTM DKA 患者接受静脉注射胰岛素（楼层或重症监护室）或 SQuID 治疗。我们比较了忠实性（使用格列美脲和含葡萄糖液体的时间）、安全性（低血糖时使用葡萄糖抢救）、有效性（阴离子间隙闭合时间、执行方案的时间）和运行效率（执行方案后申请床位的时间、EDLOS和ICU入院率）：在84名LTM DKA患者中，62人（74%）接受了SQuID治疗，22人（26%）接受了静脉注射胰岛素治疗。两组患者的治疗效果都很好。需要补充葡萄糖的患者分别为5例（8%）和4例（18%）（差异为9%，-31%至10%）。与静脉注射胰岛素组相比，SQuID 患者的阴离子间隙时间缩短了 1.4 小时（95% CI -3.4 至 0.2 小时），方案时间缩短了 10.4 小时（95% CI -22.3 至 -5.0 小时）。SQuID 队列的中位 EDLOS 为 9.8 小时（IQR 6.0-13.6），低于静脉注射胰岛素队列的 18.3 小时（IQR 13.4-22.0），但长于整个静脉注射胰岛素队列。自 SQuID 启用以来，LTM DKA 的 ICU 入院率已从 54% 降至 21% 以下：在这项单中心研究中，我们观察到，与静脉注射胰岛素相比，SQuID 具有出色的保真度、同等或更高的安全性以及临床和操作有效性。SQuID 方案已成为治疗 LTM DKA 的默认路径。自 SQuID 推出以来，LTM DKA 的 ICU 入院率下降了 33%。

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来源期刊

Academic Emergency Medicine 医学-急救医学

CiteScore

7.60

自引率

6.80%

发文量

207

审稿时长

3-8 weeks

期刊介绍： Academic Emergency Medicine (AEM) is the official monthly publication of the Society for Academic Emergency Medicine (SAEM) and publishes information relevant to the practice, educational advancements, and investigation of emergency medicine. It is the second-largest peer-reviewed scientific journal in the specialty of emergency medicine. The goal of AEM is to advance the science, education, and clinical practice of emergency medicine, to serve as a voice for the academic emergency medicine community, and to promote SAEM''s goals and objectives. Members and non-members worldwide depend on this journal for translational medicine relevant to emergency medicine, as well as for clinical news, case studies and more. Each issue contains information relevant to the research, educational advancements, and practice in emergency medicine. Subject matter is diverse, including preclinical studies, clinical topics, health policy, and educational methods. The research of SAEM members contributes significantly to the scientific content and development of the journal.