Using Quality Improvement to Design and Evaluate an Outpatient Day Treatment Pathway for Pediatric Patients with Diabetes Mellitus Requiring Insulin Initiation

Abstract

Introduction: Education and management of children with new-onset or established diabetes mellitus (DM) requiring insulin initiation do not always require hospitalization. We developed a pathway for outpatient day treatment of select patients after initial evaluation in the emergency department (ED) at a pediatric, tertiary care academic medical center.

Methods: A multidisciplinary team identified key initial eligibility criteria for outpatient day treatment for insulin initiation, including absence of diabetic ketoacidosis, age ≥3 years, and plasma beta-hydroxybutyrate (BOHB) <1 mmol/L. Electronic medical record reviews and surveys administered to endocrine providers determined exclusions or reasons for nonparticipation. Refinement of the pathway occurred through iterative plan-do-study-act cycles. Statistical process control evaluated the uptake among eligible patients.

Results: We launched the pathway in September 2020. Of 534 patients presenting to the ED with new-onset or established DM requiring insulin initiation in the first 2.5 years, 198 were potentially eligible for day treatment. Of these, 65 children (33%) completed the pathway. One additional patient was hospitalized following Day 1 of education due to newly identified psychosocial stressors. The increase of BOHB cutoff to 1.5 mmol/L and the option of rapid-acting insulin bolus for borderline BOHB resulted in a significant shift in utilization from a mean of 24.4% to 41.1%. Persistent barriers to participation include limited appointment availability, weekend presentation, and patient/family concerns.

Conclusions: Outpatient day treatment was successful for select pediatric patients with new-onset or established DM requiring insulin initiation. However, this approach necessitates flexible resources and supportive patient messaging.

Fig. 1.

Key driver diagram demonstrating the identified primary and secondary drivers necessary for successfully attaining the aim, with the associated change concepts.

Fig. 2.

Flowchart demonstrating the utilization of the DDTP-ED Referral Pathway between September 2020 and March 2023.

Fig. 3.

P-chart displaying the percentage of eligible patients participating in the DDTP-ED Referral Pathway between September 2020 and March 2023. LCL, lower control limit; UCL, upper control limit.

Fig. 4.

Pareto chart of reasons for nonparticipation in the DDTP-ED Referral Pathway between September 2021 and March 2023.