Preventing Diabetic Ketoacidosis: A Team Approach

Admissions for diabetic ketoacidosis (DKA) across the United States are increasing (1) and pose significant risk of morbidity and mortality to children with type 1 diabetes. As a pediatric endocrinologist and medical director of inpatient diabetes at Texas Children’s Hospital and assistant professor at Baylor College of Medicine, Siripoom McKay, MD works with all of her patients to prevent dangerously high blood glucose levels.  

“Every few years we have kids die because of DKA because they come in too late for us to save,” she said.  

As such, the endocrinologists at Texas Children’s Hospital work hard from the beginning to help children with type 1 diabetes live their best lives and stay consistent with their diabetes care. 

At diagnosis 

“We expect patients to have DKA at diagnosis because no one knows they need insulin,” said Dr. McKay. Texas Children’s Hospital is experienced in treating children and families who may be surprised to find themselves facing a lifelong diabetes diagnosis. At Texas Children’s Hospital, once patients are stabilized they remain in the hospital for an in-depth and multidisciplinary education on diabetes management. Families are seen by a bedside nurse who specializes in diabetes, an endocrinologist, a Clinical Diabetes Care and Education Specialist a dietician, child life, social worker and a psychologist. This includes education on insulin use, nutrition, physical activity, and managing the psycho-social aspects of diabetes. 

“Most places are doing more outpatient education these days, and the limitation of outpatient education is that parents go home at the end of that day overwhelmed with the amount of information they have received and uncertain of their abilities to manage the complexities of insulin, meals, and high and low blood sugars … Families have told us they feel more comfortable and less anxious as a result of the inpatient new onset education,” said Dr. McKay. 

Even patients who are not in DKA at the time of diagnosis are admitted so that they can take advantage of the multidisciplinary new onset diabetes team that works in concert to cover every aspect of type 1 diabetes care. The bedside nurses on the diabetes unit all receive specialized diabetes training, including monthly continuing education. These nurses teach patients and their parents how to deliver insulin and how to adjust dosages based on glucose and carbohydrate intake. The Clinical Diabetes Care and Education Specialist assesses and addresses challenges and barriers that could compromise care. Child life is also involved to address fears that children may have about needles or chronic illness. Social workers assess financial means and introduce families to community resources such as diabetes camps and support groups so that children don’t feel alone in their diabetes diagnosis. Psychologists preemptively discuss the psychological aspects of diabetes that are faced by the children and the family. 

“The physician brings it together and the message to the family is that yes, your child has type 1 diabetes, but we expect your child to have a long, normal life. All the hopes and dreams you have for your child — college, children, and all that — are still intact, but to keep your child safe, these are the additional skills you have to have,” said Dr. McKay. 

Addressing the risk of DKA in a child or adolescent with known type 1 diabetes 

Despite significant efforts at education, some children and adolescents with type 1 diabetes will still be admitted to the intensive care unit with serious complications of DKA. Once they have recovered well enough to leave the ICU, a team similar to the one involved in new onset education begins to problem solve with the patient and family.  

 “Unless we identify why the insulin is not being given by the patient and family, we can’t identify the solutions,” said Dr. McKay. 

As such, all of the specialists involved in new onset education meet in rounds with the family to discuss the patient’s barriers to appropriate diabetes care. While the bedside nurse and diabetes educators are involved to ensure that the family has the knowledge needed to succeed, they often find that a knowledge gap was not the cause of DKA. Social workers in this setting at Texas Children’s Hospital have specialized training to identify familial, social, financial or psychological barriers that will also need to be addressed to prevent subsequent DKA admissions.  

Staying safe with diabetes home management 

The involvement of clinic staff continues after discharge with frequent follow-up visits and calls to support the family.   

“In terms of common barriers, family stressor is a huge one and diabetes burnout is also a very common one,” said Dr. McKay.  

To address these and other barriers, community support can be helpful. School nurses may be involved to help keep insulin dosing consistent. A diabetes holiday, where a trusted caregiver simply takes over all diabetes care for a limited period of time, may also be suggested. Psychology referral can also be helpful for addressing issues related to diabetes burnout and difficult family situations.  

“We want to empower the child and family,” said Dr. McKay. With all of the team members who are involved in DKA treatment and prevention, the goal is for the child to feel confident in his or her ability to live a full life with their type 1 diabetes.  

To refer a patient to the Texas Children’s Diabetes and Endocrinology Program, go to  texaschildrens.org 

You can also call the Provider Connect team at 832-TCH-CARE (832-824-2273). 

[1] Everett EM et. al. (2021). National Trends in Pediatric Admissions for Diabetic Ketoacidosis, 2006-2016. J Clin Endocrinol Metab. Available at https://pubmed.ncbi.nlm.nih.gov/33942077/. Accessed May 24, 2022.