Management of hospitalized patients with mild to moderate diabetic ketoacidosis using a continuous insulin infusion protocol on a medical surgical ward and observation level of care: A retrospective cohort study.

Although the practice of using rapid-acting subcutaneous insulin for the management of mild-to-moderate diabetic ketoacidosis is becoming increasingly popular, the continuous insulin infusion remains widely utilized, and its real-world applicability and safety on a medical surgical unit (Med Surg) and observation level of care are unclear. We assessed whether a continuous insulin infusion protocol for mild-to-moderate diabetic ketoacidosis on Med Surg/observation level of care over a 6.5-year period was associated with adverse outcomes. A retrospective cohort study of adults hospitalized with mild-to-moderate diabetic ketoacidosis was conducted at 2 community hospitals in Northern California, USA, from January 2014 to May 2020. Demographic and clinical variables were collected using an electronic health record. Admission to Med Surg/observation was compared to intensive care unit admission for the outcomes of 30-day readmission, presence of hypoglycemia, rate of hypoglycemic episodes, in-hospital and 30-day mortality, and length of stay using bivariate analysis. Among 227 hospital encounters (mean age 41 years, 52.9% women, 79.3% type 1 diabetes, 97.4% utilization of continuous insulin infusion), 19.4% were readmitted within 30 days, and 20.7% developed hypoglycemia. For Med Surg/observation encounters compared to the intensive care unit, there were no statistically significant differences in the risk of readmission (RR 1.48, 95% CI, 0.86-2.52), hypoglycemia (RR 1.17, 95% CI, 0.70-1.95), or increased length of stay (RR 0.71, 95% CI, 0.55-1.02); there was a lower risk of hypoglycemic events during hospitalization (RR 0.69, 95% CI, 0.54-0.96). Continuous insulin infusion utilization may be a safe option for treatment of mild-to-moderate diabetic ketoacidosis on Med Surg/observation level of care. Further investigation is needed.

Association of Positive Fluid Balance at Discharge After Sepsis Management With 30-Day Readmission.

Importance: Although early fluid administration has been shown to lower sepsis mortality, positive fluid balance has been associated with adverse outcomes. Little is known about associations in non-intensive care unit settings, with growing concern about readmission from excess fluid accumulation in patients with sepsis. Objective: To evaluate whether positive fluid balance among non-critically ill patients with sepsis was associated with increased readmission risk, including readmission for heart failure. Design, Setting, and Participants: This multicenter retrospective cohort study was conducted between January 1, 2012, and December 31, 2017, among 57 032 non-critically ill adults hospitalized for sepsis at 21 hospitals across Northern California. Kaiser Permanente Northern California is an integrated health care system with a community-based population of more than 4.4 million members. Statistical analysis was performed from January 1 to December 31, 2019. Exposures: Intake and output net fluid balance (I/O) measured daily and cumulatively at discharge (positive vs negative). Main Outcomes and Measures: The primary outcome was 30-day readmission. The secondary outcomes were readmission stratified by category and mortality after living discharge. Results: The cohort included 57 032 patients who were hospitalized for sepsis (28 779 women [50.5%]; mean [SD] age, 73.7 [15.5] years). Compared with patients with positive I/O (40 940 [71.8%]), those with negative I/O (16 092 [28.2%]) were older, with increased comorbidity, acute illness severity, preexisting heart failure or chronic kidney disease, diuretic use, and decreased fluid administration volume. During 30-day follow-up, 8719 patients (15.3%) were readmitted and 3639 patients (6.4%) died. There was no difference in readmission between patients with positive vs negative I/O (HR, 1.00; 95% CI, 0.95-1.05). No association was detected between readmission and I/O using continuous, splined, and quadratic function transformations. Positive I/O was associated with decreased heart failure-related readmission (HR, 0.80 [95% CI, 0.71-0.91]) and increased 30-day mortality (HR, 1.23 [95% CI, 1.15-1.31]). Conclusions and Relevance: In this large observational study of non-critically ill patients hospitalized with sepsis, there was no association between positive fluid balance at the time of discharge and readmission. However, these findings may have been limited by variable recording and documentation of fluid intake and output; additional studies are needed to examine the association of fluid status with outcomes in patients with sepsis to reduce readmission risk.