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BMJ Open Diabetes Res Care. 2019 Aug 18;7(1):e000695. doi: 10.1136/bmjdrc-2019-000695. eCollection 2019.

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

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Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.
Institute of Applied Health Research, University of Birmingham, Birmingham, UK.
Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.



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


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.


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.


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.


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.


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.


Based on these results, we recommend regular audit and feedback is required to sustain improvements in DKA management.


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

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