Comparison of Outcomes and Costs Between Adult Diabetic Ketoacidosis Patients Admitted to the ICU or Stepdown Unit
CCCF ePoster library. Fernando S. Nov 8, 2018; 233430; 51
Dr. Shannon Fernando
Dr. Shannon Fernando
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Introduction: There is wide variation in the utilization of Intensive Care Unit (ICU) beds for treatment and monitoring of adult patients with Diabetic Ketoacidosis (DKA). In some centres, all DKA patients are admitted to the ICU, while in others, these patients are admitted to step-down units, where close monitoring can still be provided. Given the limited availability of ICU beds, the effectiveness of such step-down units must be evaluated.  


Objectives: We sought to compare the outcomes and costs of adult DKA patients admitted to an ICU against those admitted to a step-down unit.


Methods: We utilized prospectively collected registry data gathered from 2011-2016 at two hospitals in Ottawa, ON. We included consecutive patients admitted to hospital, and who met diagnostic criteria for DKA (as defined by the American Diabetes Association). Patients were either admitted to the ICU, or a step-down unit, which has a nurse-to-patient ratio of 2:1, but does not have capability for mechanical ventilation or administration of vasoactive agents. Patients admitted to ICU for reasons other than DKA were excluded. Patients requiring treatment that could not be provided in the step-down unit (e.g. mechanical ventilation, vasoactive agents) were similarly excluded. The primary outcome was in-hospital mortality, analyzed using a multivariable logistic regression model, adjusting for age, comorbidities, and illness severity. We secondarily evaluated total hospital costs, with variation in total costs assessed using a multivariable generalized linear model with log link. A gamma distribution was applied.  


Results: 872 patients were included in analysis, of which 71 (8.1%) were admitted to ICU, while the remaining 801 (91.9%) were admitted to a stepdown unit. In both groups, patients predominantly had Type 1 Diabetes Mellitus (80.5% in ICU vs. 78.7% in step-down, P = 0.70), and no differences in chronic complications from diabetes were found. There was no difference in median venous pH at admission (7.07 in ICU vs. 7.10 in step-down, P = 0.17). The most common precipitant for DKA in both cohorts was medication non-compliance (83.1% in ICU vs. 86.2% in step-down, P = 0.41). 65 total patients died in-hospital (7.5%). No difference in in-hospital mortality was found between patients admitted to the ICU and those admitted to the step-down unit (adjusted OR: 1.14, 95% CI: 0.87-2.64). Mean total costs were significantly higher for patients admitted to the ICU ($20,428 vs. $6,484, P < 0.001). Admission to ICU had an independent effect on total costs in the generalized linear model (coefficient 2.26, P < 0.001).


Conclusions: Adult DKA patients admitted to a step-down unit had comparable in-hospital mortality and lower overall costs than those admitted to the ICU. Individual hospitals should consider such step-down units in order to reduce resource utilization and overall costs. 

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