Regular performance feedback may be key to maintain good quality DKA management: results from a five-year study

Punith Kempegowda, Joht Singh Chandan, Benjamin Coombs, Anne De Bray, Nitish Jawahar, Sunil James, Sandip Ghosh, Parth Narendran

Research output: Contribution to journalArticlepeer-review

1 Citation (Scopus)
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Objectives We postulate that performance feedback is a prerequisite to ensure sustained improvement in diabetic ketoacidosis (DKA) management.

Design The study was based on ‘theory of change’ concept that suggests changes of primary drivers determine the main outcome. A set of secondary drivers can be implemented to achieve improvements in these primary drivers and thus the main outcome.

Setting This study was conducted at a large tertiary care center in the West Midlands, UK. The region has above average prevalence of diabetes and DKA admissions in the country.

Participants All participants diagnosed with DKA as per national guidelines, except those managed in intensive care unit from April 2014 to March 2018, were included in this study.

Interventions Monthly feedback of performance was the main intervention. Development of a real-time live DKA audit tool, automatic referral system of DKA to the specialist team, electronic monitoring of blood gas measurements and education and redesigning of local (trust) guidelines were the other interventions in this study.

Main outcome measures Total DKA duration, appropriateness of fixed rate intravenous insulin infusion, fluid prescription, glucose monitoring, ketone monitoring and referral to specialists.

Results There was a significant reduction in the duration of DKA postintervention compared with baseline results. However, in the absence of regular feedback, the duration of DKA showed an upward trend nearing baseline values. Similar trends were noted in secondary drivers influencing DKA duration.

Conclusion Based on these results, we recommend regular audit and feedback is required to sustain improvements in DKA management.
Original languageEnglish
Article numbere000695
JournalBMJ Open Diabetes Research and Care
Issue number1
Early online date18 Aug 2019
Publication statusPublished - 18 Aug 2019

Bibliographical note

Funding Information:
This study was conducted at the Queen Elizabeth Hospital Birmingham, part of the University Hospitals Birmingham National Health Service (NHS) Foundation Trust. As one of the busiest NHS organizations, it saw more than 135 000 inpatient episodes and over 115 000 emergency department attendances (~315 patients, daily) over the course of 2016/2017.25

Publisher Copyright:
© 2019 Author(s).


  • Endocrinology/Diabetology
  • Insulin-Deficient Type 1 Diabetes
  • Ketoacidosis
  • Quality Improvement Measures

ASJC Scopus subject areas

  • Endocrinology, Diabetes and Metabolism


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