Date of Graduation


Document Type


Degree Type



School of Nursing

Committee Chair

Kendra Barker

Committee Member

Charles Mullett

Committee Member

Lya Cartwright-Stroupe


Background: Diabetic ketoacidosis (DKA) is a serious complication of diabetes that occurs when the body compensates for insufficient insulin, producing dangerously high levels of ketones. Without proper treatment, DKA can be fatal. For that reason, staff in the pediatric intensive care unit (PICU) at a tertiary care hospital in northern West Virginia expressed concerns about the complexity of and lack of adherence to a poorly referenced and dated DKA treatment protocol.

Objective: The purpose of this project was to assess the feasibility and sustainability of optimizing the DKA protocol in the PICU. The primary objective was to implement an updated, simplified, evidence-based DKA protocol in the PICU to promote adherence by staff members.

Methods: A literature search was performed based on the PICOT question “In pediatric patients, how does using a protocol to manage DKA compared to not using a protocol affect patient outcomes throughout hospital admission?” A total of 26 articles were used: 6 that directly supported implementation of a DKA protocol, and 20 that supported various aspects of DKA management that were essential for an updated, evidence-based protocol. Based on these, updates were made to the existing protocol to make it easier to use but still conform to clinical guidelines set forth by the International Society for Pediatric and Adolescent Diabetes (ISPAD). The Duffy Quality-Care Model and the Star Model of Knowledge Transformation were the theoretical frameworks for this project. Focus groups were used to assess demand and practicality for the protocol changes and assimilate the evidence-based guidelines into the revised protocol. Staff was educated to the changes, and the revised protocol was implemented for a 90-day trial period. Staff satisfaction and protocol usage evaluation were evaluated through staff surveys with both quantitative Likert scale data and qualitative open-ended question data. Rapid cycle quality improvement strategies of staff interviewing and survey data analysis were used to troubleshoot protocol issues during the trial period.

Results: Using evidence-based literature, a fully optimized DKA protocol was successfully developed and implemented in the PICU. Feasibility of long-term sustainability was confirmed by staff surveys with 78.9% reporting they were likely to use the new protocol. There was report through the interview and open-ended question answers that patient glucose levels remained high longer with the new protocol, though the acidosis still corrected without issue, leading to the identification of a missed logic step in the protocol algorithm for rebound hyperglycemia during the dextrose infusion. There were no medical complications related to this missed step, but it was identified as an area of the protocol needing further development.

Discussion: Though there was a high percentage of staff members reporting they were likely to use the new protocol, there were mixed results for whether the old or new protocol was preferred. The missed step in the algorithm for rebound hyperglycemia with the dextrose infusion is under review by the PICU medical staff, but recommendations have not yet been determined for appropriate correction as this rebound hyperglycemia also has some protective effects against hypoglycemia during acidosis correction. Attention to this issue with the algorithm will likely improve staff satisfaction with the protocol.

Conclusion: At present, the PICU staff plan a sustained adoption of the revised DKA protocol. Using an algorithmic, evidence-based DKA protocol standardizes care provided to patients, reducing morbidity and mortality and promoting patient safety and improved patient outcomes.