30 Reducing iatrogenic low blood glucose episodes during hospital management of pediatric diabetic ketoacidosis

Background IV insulin therapy, the treatment for pediatric diabetic ketoacidosis (DKA), may lead to iatrogenic low blood glucose episodes (BG Objectives We aimed to decrease the percent of DKA patients experiencing BG Methods Multiple interventions linked to key drivers were tested using plan-do-study-act cycles including a standardized DKA guideline incorporating the two-bag fluid system, order panels, frequent blood glucose monitoring, and provider and nursing education. The primary outcome was the percent of DKA patients experiencing a BG 17), and admission rates. All outcomes were analyzed on statistical process control charts. Results From January 2017 through August 2019, 334 patients had confirmed DKA (bicarbonate level Conclusions Use of QI methodology and standardized DKA management resulted in a meaningful reduction in the number of patients with a BG