SAT-LB109 Implementation of a Quality Improvement Initiative for Advanced Ketone Management in Children With Recently Diagnosed Type 1 Diabetes
Authors: Jindal Ishita , Gammons Sarah , Merchant Nadia , Moryan-Blanchard Kristen , Jarrin Marcela Fernanda Astudillo , Al-Gadi Iman , Lyons Sarah 
Published: May 2020

Abstract
Background: Monitoring of blood glucose, ketones and/or adjustment of the daily insulin dose is usually required with intercurrent illness in children with type 1 diabetes (T1D). International Society for Pediatric and Adolescent Diabetes recommends sick day guidelines, including insulin adjustments, should be taught soon after diagnosis. At our center, caregivers of children with newly diagnosed T1D receive extensive inpatient education, including introduction to sick day management. However, there was no standardized education for calculation of extra insulin doses to treat ketosis, i.e. advanced ketone management. This resulted in increased calls for ketone management and potential readmissions to the hospital.Objectives: Through a quality improvement (QI) initiative, we aimed to (1) provide standardized education on advanced ketone management to 50% of patients with a new diagnosis of T1D, aged 5-18 years, at their initial outpatient visit within four weeks of diagnosis, and (2) decrease the number of telephone calls for management of ketosis without increasing calls for hypoglycemia.Methods: Baseline data for telephone calls pertaining to ketosis or hypoglycemia management, within four weeks of diagnosis, were collected retrospectively by chart review for all children with new onset T1D, aged 5-18 years, from April 2018 to September 2018 (n=23). Through a series of plan-do-study-act (PDSA) cycles, a standardized ketosis management patient education bundle and ketone dose calculation tool were created. A pre-assessment questionnaire was used to determine eligibility at the initial follow up visit, within four weeks of diagnosis. Advanced ketone management education was provided to eligible patients. A post-assessment questionnaire was used to assess retention of knowledge at the next follow-up visit. Results: Forty-two children were diagnosed with new onset diabetes from January 2019 to May 2019. Of these, 30 children (71%) qualified to participate in the QI project and were given pre-assessment questionnaires. Twenty children (67%) were eligible to receive education on advanced ketone management. Of these, 95% children received standardized education at their initial outpatient visit. One child did not receive education due to time constraints and education was provided at the next follow-up visit. 70% eligible children received post-assessment questionnaires and of these, 100% scored ≥70%. Telephone calls for ketosis management decreased (26% to 6%, p&lt;0.001), but there was no change in calls for hypoglycemia (52% to 48%).Conclusion: Standardized education on advanced ketone management is feasible to be provided within four weeks of diagnosis of T1D. This can decrease telephone calls for sick day ketosis management without increasing calls for hypoglycemia. This can likely result in reduction of parental anxiety and diabetes related hospital readmissions.