Recurrent diabetic ketoacidosis admissions: gaps in education, discharge safety-netting and psychosocial support

A retrospective service evaluation informing a Quality Improvement Project

Abstract

Background: Diabetic ketoacidosis (DKA) remains a common cause of emergency admission in people with type 1 diabetes (T1DM) and is associated with significant morbidity and mortality. Recurrent DKA admissions may reflect unmet needs beyond acute metabolic management, including gaps in structured education, discharge safety-netting and psychosocial support. Understanding local patterns of recurrent DKA is essential to inform preventative strategies.

Methods: We conducted a retrospective service evaluation at a large teaching hospital between 1st July and 31st December 2024. This study was designed as a baseline evaluation informing the first stage of a multi-cycle quality improvement (QI) project, conducted in accordance with SQUIRE 2.0 guidelines. Routinely collected, clinically coded discharge data were used to identify adults with T1DM admitted with DKA. Recurrent DKA was defined as two or more admissions within a rolling 12-month period, assessing admissions during the study window. Lifetime admissions within the cohort were also studied. Electronic health records were reviewed to identify demographic characteristics, documented triggers, psychosocial factors and sick-day rule education documentation. A survey of resident doctors was conducted to assess training exposure and confidence in delivering DKA prevention education.

Results: The 210 DKA admissions during the evaluation period corresponded to 57 unique adult patients with T1DM, of whom 41 (72%) were identified as having recurrent DKA (59% female [n=24]; 73% White British [n=30], 17% Asian [n=7], 5% Black or African [n=2], 5% Mixed ethnicity [n=2]). Admissions were concentrated within a small number of individuals: 17 patients (41%) had 2-4 lifetime DKA admissions, 16 patients (39%) had 5-9 admissions, and 8 patients (20%) had 10 or more admissions. Documented sick-day rule education was present in 61% of patients (n=25), absent in 34% (n=14), and 5% (n=2) self-discharged prior to diabetes team review. Psychosocial triggers were identified in a subset of patients, with mental health conditions and substance misuse most frequently documented among those with the highest admission frequencies. Of 20 resident doctors surveyed, only 35% (n=7) reported receiving formal teaching on sick-day rules, and 85% (n=17) reported low confidence in delivering personalised written discharge advice.

Conclusion: Recurrent DKA admissions are concentrated within a small, high-risk cohort and are associated with deficiencies in inpatient education, discharge safety-netting and psychosocial support. These findings support recurrent DKA as a marker of psychological and social vulnerability. This baseline evaluation identifies clear targets for a multi-faceted preventative quality improvement approach, including standardised discharge documentation, clinician education and integrated psychosocial support.