Integrated Care Pathway for the Management of Children and

Integrated Care Pathway for the Management of Children and Young People with Diabetic Ketoacidosis

V3.1

February 2021

Integrated Care Pathway for the Management of Children and Young People with Diabetic Ketoacidosis V3.1 Page 2 of 28

Summary This guideline provides a pathway for management of Diabetic Ketoacidosis (DKA) in Children and Young People which has been nationally approved by the British Society for Paediatric Endocrinology and Diabetes (BSPED). This pathway gives general guidance for management. Treatment may need modification to suit individual patients and this document does not remove the need for frequent detailed reassessments of the patient’s requirements and treatment. Please see the document for a further summary and safety notes at the start of the pathway. It has been agreed within the Trust that this pathway can be used in the BSPED format.


1. Aim/Purpose of this Guideline

1.1. The Integrated Care Pathway (ICP) is designed to be used by, or under the supervision of, clinicians experienced in the management of paediatric DKA.

It should be used in conjunction with the full BSPED DKA 2020 guideline on which it is based which can be found here:

https://www.bsped.org.uk/media/1742/dka-icp-2020-v1_1.pdf

1.2. The “dka-calculator” version supersedes any previous versions of this document.

From a governance perspective the calculator states: “No Patient identifiable data is transmitted or stored when using the online calculator.”, so consent for using the calculator is not required.

2. The Guidance

2.1. The British Society for Paediatric Endocrinology and Diabetes (BSPED) have confirmed in writing that their Integrated Care Pathway (ICP) for the Management of Children and Young People with Diabetic Ketoacidosis can be used within our Trust.

2.2. Please use the following link to print off the ICP because it undertakes all the calculations prior to printing and should reduce calculation errors: https://dka-calculator.co.uk/

In order to print the ICP from the DKA calculator page you will need to have performed your primary ABC assessment and blood gas because you will need to input the following information: patient demographics, weight, pH and whether they are shocked.

Data Protection Act 2018 (General Data Protection Regulation – GDPR) Legislation

The Trust has a duty under the DPA18 to ensure that there is a valid legal basis to process personal and sensitive data. The legal basis for processing must be identified and documented before the processing begins. In many cases we may need consent; this must be explicit, informed and documented. We cannot rely on opt out, it must be opt in.

DPA18 is applicable to all staff; this includes those working as contractors and providers of services.

For more information about your obligations under the DPA18 please see the Information Use Framework Policy or contact the Information Governance Team [email protected]

https://dka-calculator.co.uk/

mailto:[email protected]


You will also need to choose your insulin infusion rate and we would recommend starting at 0.05units/kg/hour.

The pathway should be used in conjunction with the full BSPED DKA 2020 guideline on which it is based which can be found here: https://www.bsped.org.uk/media/1742/dka-icp-2020-v1_1.pdf If for some reason the direct links above aren’t working then the guideline, blank ICP and DKA calculator should all be available via the BSPED website at https://www.bsped.org.uk/clinical-resources/guidelines/. If all of those links fail then as a last resort the ICP can be printed off from Appendix 3.

2.3. There are some management options given in the ICP/guideline:

Insulin dose (asked on the DKA calculator homepage and on Page 7 Flowchart 5 of the ICP):

o Start with 0.05units/kg/hour initially, and aim to increase this after 6-8 hours if there is persistent acidosis (See page 9 flow chart 7 and increase insulin). If persistent acidosis that does not look like it is a ketotic acidosis, suggest use Flow chart 11 for persistent acidosis, where box 2 suggests to check insulin infusion calculation. Then probably increase to 0.1units/kg/hour before other treatments. This may require increasing the percentage concentration of dextrose up to 10% to deliver the increased insulin to turn of ketoacidosis whilst maintaining high enough glucose levels.

Long-acting insulin (Page 7, Flow chart 5):

o Newly diagnosed patients: start long-acting insulin on the first bedtime of admission (if they are admitted after bedtime then this can be started the following day).

o Established patients: you can prescribe the long-acting insulin to be given at their usual time.

2.4. If you are struggling with using the guideline, then please see the following

links that include some demonstration patient details inserted that might help.

For doctors: LINK TO CHILD HEALTH MEDICAL DKA TEACHING LINKS FOLDER: S:\RCH-WCSH\Child Health\Medical\Guidelines\Diabetes\Diabetes DKA Teaching july 2020 information hyperlinks and presentations.docx

For nurses:

https://www.bsped.org.uk/clinical-resources/guidelines/


LINK TO CHILD HEALTH NURSING EDUCATION FOLDER: S:\RCH-WCSH\Nursing Education\Diabetes

If you do not have access to those folders, then someone else on the shift should do and will be able to show you. Or you can discuss with the on call paediatric consultant. Or in hours, access can be arranged for doctors by contacting the Rota Coordinator and for nursing staff by contacting the Paediatric Practice Development Nurse.

Included are some presentations about how the DKA pathway has changed from the previous pathways and the new evidence base for these changes. At the time of guideline publication in July 2020 the best link is the first don’t forget the bubbles DKA link. The links are:

https://dontforgetthebubbles.com/diabetic-ketoacidosis/ https://www.bsped.org.uk/media/1742/dka-icp-2020-v1_1.pdf https://dontforgetthebubbles.com/sweet-salty-fluids-dka/ https://www.paediatricfoam.com/2017/02/diabetic-ketoacidosis-dka/

https://dontforgetthebubbles.com/diabetic-ketoacidosis/

https://www.bsped.org.uk/media/1742/dka-icp-2020-v1_1.pdf

https://dontforgetthebubbles.com/sweet-salty-fluids-dka/

https://www.paediatricfoam.com/2017/02/diabetic-ketoacidosis-dka/


3. Monitoring compliance and effectiveness

Element to be monitored

There is a plan to monitor DKA nationally every 3 years from the Association of Children’s Diabetes Clinicians (ACDC), although most of this has been around the process and staffing, rather than the medical management. The Paediatric Diabetes department at RCHT have sent in this data, and it has been recorded in our Peer Review returns, as well as presentation at local guidelines

Lead Dr Simon Robertson, Consultant Paediatrician

Tool We have in the past looked at the numbers of patients in DKA, the fluid calculations, use of saline boluses and rate of cerebral oedema, evidence of hypoglycaemia (which fed back at network and nationally to change the insulin infusion rate)

This was a self-created audit sheet which we will repeat with the new guidelines to ensure our teaching on the subject has been effective.

Frequency We will monitor the outcomes every 3 years. (About 10-15 DKA admissions per year)

Reporting arrangements

Who or what committee will the completed report be sent to: Local Paediatric Audit and Guidelines group

How will each report be interrogated to identify the required actions and how thoroughly should this be documented in e.g. meeting minutes.- The audit will be studied in the diabetes team meetings then presented to the Paediatric Audit and Guidelines group. This will then be summarized in the meeting minutes, with actions being followed in the action log to ensure they are completed. Sometimes this data has been presented to the SWPDN meeting if interesting findings arise.

Acting on recommendations and Lead(s)

Local Paediatric Audit lead will ensure paediatric diabetes team continue to audit and complete recommendations

Change in practice and lessons to be shared

Lessons learned will be disseminated as part of the on-going peadiatric diabetes training programme for junior doctors every 6 months and ward nursing staff annual mandatory paediatric training. Cases are frequently discussed at the annual PICU roadshow which can include CCU and ED consultants and nursing staff, as these are the current users of this guideline..

4. Equality and Diversity

4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Inclusion & Human Rights Policy' or the Equality and Diversity website.

4.2. Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2.

http://www.rcht.nhs.uk/GET/d10268876

http://www.rcht.nhs.uk/GET/d10268876

http://intranet-rcht.cornwall.nhs.uk/shelf/equality-and-diversity/


Appendix 1. Governance Information

Document Title Integrated Care Pathway for the Management of Children and Young People with Diabetic Ketoacidosis V3.0

This document replaces (exact title of previous version):

Diabetic Ketoacidosis – Clinical Guideline for Management Of a Child or Young Person V3.0

Date Issued/Approved: February 2021

Date Valid From: February 2021

Date Valid To: August 2023

Directorate / Department responsible (author/owner):

Dr Simon Robertson, Consultant Paediatrician

Contact details: 01872 252802

Brief summary of contents An Integrated Care Pathway which has been nationally approved by the British Society for Paediatric Endocrinology and Diabetes

Suggested Keywords: Children, Paediatric, Pediatric, Diabetes, Diabetic, Ketoacidosis, keto-acidosis, DKA.

Target Audience RCHT CFT KCCG

Executive Director responsible for Policy:

Medical Director

Approval route for consultation and ratification:

Child Health/ Paediatrics Clinical Guidelines and Audit Meeting

General Manager confirming approval processes

Mary Baulch

Name of Governance Lead confirming approval by specialty and care group management meetings

Caroline Amukusana

Links to key external standards

BSPED Interim Guideline for the Management of Children and Young People under the age of 18 years with Diabetic Ketoacidosis April 2020: https://www.bsped.org.uk/media/1745/bsped-dka-guidelines-no-dka-link.pdf . NICE guideline (NG18) 2015: https://www.nice.org.uk/guidance/ng18/chapter/1-Recommendations#diabetic-ketoacidosis-2 (although this is due to be updated). ,ISPAD Guidelines 2018 chapter 11 on DKA: https://cdn.ymaws.com/www.ispad.org/resource/resmgr/consensus_guidelines_2018_/11.diabetic_ketoacidosis_and.pdf

Related Documents: None

https://www.nice.org.uk/guidance/ng18/chapter/1-Recommendations#diabetic-ketoacidosis-2

https://www.nice.org.uk/guidance/ng18/chapter/1-Recommendations#diabetic-ketoacidosis-2

https://cdn.ymaws.com/www.ispad.org/resource/resmgr/consensus_guidelines_2018_/11.diabetic_ketoacidosis_and.pdf




Training Need Identified?

Yes- training at junior, middle grade and senior doctors and paediatric ward nurses, ED and CCU nurses undertaken by diabetes team

Publication Location (refer to Policy on Policies – Approvals and Ratification):

Internet & Intranet

Intranet Only

Document Library Folder/Sub Folder

Clinical / Paediatrics

Version Control Table

Date Version

No Summary of Changes

Changes Made by (Name and Job Title)

Feb 2016

V1.0

Initial Issue

SW Paediatric Diabetes Network

July 2016

V2

RCHT version Changes in initial blood tests

Dr Simon Robertson Consultant Paediatrician

July 2020 V3.0 Full review and pathway replaced with most up to date Nationally recognised BSPED

pathway.

Dr Simon Robertson and Dr Katie Mallam Consultant Paediatricians

February 2021

V3.1 1.1 Font made larger in order for it to stand out and BSPED DKA link updated 2.2 Font amended in order for it to stand out and BSPED DKA link updated Instructional text added at the start of Appendix 3

Dr M Thorpe, Consultant Paediatrician

All or part of this document can be released under the Freedom of Information

Act 2000

This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing

Controlled Document

This document has been created following the Royal Cornwall Hospitals NHS Trust Policy for the Development and Management of Knowledge, Procedural and Web

Documents (The Policy on Policies). It should not be altered in any way without the express permission of the author or their Line Manager.


Appendix 2. Initial Equality Impact Assessment

Section 1: Equality Impact Assessment Form

Name of the strategy / policy /proposal / service function to be assessed Integrated Care Pathway for the Management of Children and Young People with Diabetic Ketoacidosis V3.0

Directorate and service area: Child Health

Is this a new or existing Policy? Existing

Name of individual/group completing EIA Dr Simon Robertson

Contact details: 01872252716

1. Policy Aim Who is the strategy / policy / proposal / service function aimed at?

Any medical personnel in RCHT dealing with the diagnosis and management of DKA in children and Young people under the age of 16, or under 19 if still within the children’s diabetes service.

2. Policy Objectives To use the updated national guideline

3. Policy Intended Outcomes

To safely manage DKA in young people in accordance with best practice. In particular, to communicate effectively with the specialist services, manage the young person in the appropriate location, with the correct fluids, insulin and monitoring for the complications of DKA management.

4. How will you measure the outcome?

See section 3

5. Who is intended to benefit from the policy?

Children and Young People with diabetes presenting in DKA

6a). Who did you consult with?

b). Please list any groups who have been consulted about this procedure.

Workforce Patients Local groups

External organisations

Other

x

Please record specific names of groups: Child Health Guidelines Group

c). What was the outcome of the consultation?

Approved


7. The Impact Please complete the following table. If you are unsure/don’t know if there is a negative impact you need to repeat the consultation step. Are there concerns that the policy could have a positive/negative impact on:

Protected Characteristic

Yes No Unsure Rationale for Assessment / Existing Evidence

Age

X

The adult and paediatric DKA guidelines are considerably different. This is as a result of research that shows children and young people are at a higher risk of cerebral oedema than adults. There are therefore different fluid and insulin regimes. The cut-off for admission of patients to the children’s diabetes service is currently 16 years. There are however 16 year old patients with known diabetes still in the transition period to adult diabetes services. These patients would be managed by the paediatric team, where those presenting after their 16 birthday are not admitted under paediatrics. Because the in patient diabetes guidelines are very different for adults and children, the paedaitric wards will only manage children with the paediatric guidelines, and adult wards will only admit and treat using the adult guidelines because of patient safety. This is in agreement with both the adult and children’s diabetes teams.

Sex (male, female non-binary, asexual etc.)

X

Gender reassignment X

Race/ethnic communities /groups

X

Any information provided should be in an accessible format for the parent/carer/patient’s needs – i.e. available in different languages if required/access to an interpreter if required

Disability (learning disability, physical disability, sensory impairment, mental health problems and some long term health conditions)

X

Those parent/carer/patients with any identified additional needs will be referred for additional support as appropriate - i.e to the Liaison team or for specialised equipment. Written information will be provided in a format to meet the family’s needs e.g. easy read, audio etc

Religion/ other beliefs X

All staff should be aware of any beliefs that may impact on the decision to treat

Marriage and civil partnership X

Pregnancy and maternity

X

As above, there are differences between children and adult DKA guidelines. Once a young woman of any age is pregnant, she is transferred to the adult service who have the necessary experience to manage the complications of diabetes management in pregnancy. The young woman would then stay under the adult team, whatever age she is.


Sexual orientation (bisexual, gay,

heterosexual, lesbian) X

If all characteristics are ticked ‘no’, and this is not a major working or service change, you can end the assessment here as long as you have a robust rationale in place.

I am confident that section 2 of this EIA does not need completing as there are no highlighted risks of negative impact occurring because of this policy.

Name of person confirming result of initial impact assessment:

Dr Simon Robertson

If you have ticked ‘yes’ to any characteristic above OR this is a major working or service change, you will need to complete section 2 of the EIA form available here: Section 2. Full Equality Analysis For guidance please refer to the Equality Impact Assessments Policy (available from the document library) or contact the Human Rights, Equality and Inclusion Lead [email protected]

http://doclibrary-rcht-intranet.cornwall.nhs.uk/DocumentsLibrary/RoyalCornwallHospitalsTrust/ChiefExecutive/Templates/Section2FullEqualityAnalysis.docx

mailto:[email protected]


Appendix 3 – Integrated Care Pathway (ICP) for the Management of Children and Young People with Diabetic Ketoacidosis. The British Society for Paediatric Endocrinology and Diabetes (BSPED) have confirmed in writing that the following pathway can be used within our Trust. The ICP should be printed off from the website links in Section 2.2.

Appendix 3 should only be printed off if those links are not working. Appendix 3 is not page numbered to correspond with the rest of this document, the page numbers (and appendix included in the pathway) relate only to the ICP.


Do NOT use pages below if https://dka-calculator.co.uk/ is working

https://dka-calculator.co.uk/










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