(1290) A QI Project to Decrease CT Head Imaging in Pediatric Patients With DKA and Altered Mental Status

Introduction: Cerebral edema (CE) is common in pediatric patients with diabetes ketoacidosis (DKA). Its diagnosis and treatment do not require radiologic confirmation by head CT scans (HCT). The aim of our project was a 50% decrease of HCT utilization in DKA patients presenting with altered mental status without a focal neurological deficit to the Pediatric Intensive Care Unit (PICU). Our secondary goal was to increase osmotherapy without delay due to imaging.

Methods: We used the Plan-Do-Study-Act (PDSA) quality improvement method. De-identified data from patients admitted with a diagnosis of DKA was obtained from the Children’s Wisconsin local Virtual Pediatric Systems, LLC database (VPS) and by chart review. Baseline data calculating the percentage of PICU DKA admissions with a HCT performed and percentage of patients receiving osmotherapy without a HCT performed between January 2015 and October 2018 was obtained. The first intervention occurred in May 2019 and consisted of education with updated clinical guidelines via lecture series of PICU and ER providers. The next step was creating a best practice alert (BPA) within the electronic health record. The BPA was activated anytime a HCT was ordered on any patient with an order for an insulin drip and a documented glucose of greater than 400 mg/dl. The BPA recommended reconsidering the use of a HCT in absence of focal neurological deficits and suggested using osmotherapy if clinical signs of CE were present. Data was analyzed using statistical process control (SPC) charts.

Results: A total of 242 admissions were analyzed. Of these, 125 (52%) were during the post intervention period. The percentage of HCT utilization decreased from 34.2% during the pre-intervention period to 13.6% after interventions implementation. Osmotherapy use without HCT increased from 1.6% in the pre intervention period to 8.8% in the post intervention period. There were no episodes of cerebral herniation in the pre or post intervention periods.

Conclusions: This project was able to decrease HCT utilization, resulting in less radiation exposure and cost savings. Secondly, there was increased use of osmotherapy without HCTs, which suggests earlier treatment of clinical CE.