Ilona Lorincz, MD
Nikhil Mull, MD
Cassie Bellamy, PharmD
Angela Mills, MD
Clinton Orloski, MD
Stephanie Maillie, MSN, RN, CCRN, CCNS
Marybeth O'Malley, MSN, RN, ACNS-B
Joyce Finnegan, BSN, RN, CEN
Innovation Accelerator Program
Diabetic ketoacidosis (DKA) is a serious complication of diabetes that occurs when a patient's body produces high levels of blood acids called ketones.
When we started this work, there were approximately 200-300 annual admissions for DKA at the Hospital of the University of Pennsylvania (HUP). An analysis of the emergency department (ED) treatment pathway for DKA showed seven guidelines in use and no consensus around appropriate treatment. Long-held conventions dictated for care to be delivered in the intensive care unit (ICU) despite research showing that level of care to be unnecessary for DKA.
TargetPath is a comprehensive program designed to translate evidence-based guidelines into action at the bedside.
Patients at risk for DKA are identified using a dashboard that monitors admissions into the ED, and ED providers are prompted via text message to enact just-in-time, evidence-based protocols when patients fulfill care criteria.
The clinician-designed protocol is devised to be actionable and easy to use so that multidisciplinary care teams can provide efficient, high-value, consistent care to patients with DKA. And when it’s time for transfer from the ED, huddles with pharmacists ensure the safe transition of care.
By decreasing care variations and appropriately triaging patients based on the level of care required, TargetPath enables more patients to go directly home from ED, freeing up ICU beds for sicker patients.
During the initial pilot at HUP, TargetPath led to savings of half a day of length of stay for all DKA patients and cut ICU utilization in half. Following the pilot, supporting order sets were built into the electronic health record to guide workflows and further reinforce the pathway.
TargetPath is the standard of care for patients at risk for DKA at HUP. The team's insights and approach to refining and optimizing evidence-based guidelines serve as a roadmap for other clinical teams working to implement standardized care delivery.
Fake front end
Fake front end
We collected feedback from providers as they utilized multiple paper iterations of the pathway. Insights from this process helped us implement more specific inclusion criteria and a better user experience.
Fake front end
High-fidelity learning can come from low-fidelity deployment.
Mini-pilots will allow you to learn by doing, usually by deploying a fake back end. You might try a new intervention with ten patients over two days in one clinic, using manual processes for what might ultimately be automated.
Running a "pop-up" novel clinic or offering a different path to a handful of patients will enable you to learn what works and what doesn't more quickly. And, limiting the scope can help you gain buy-in from stakeholders to get your solution out into the world with users and test safely.
We piloted a targeted intervention unit in the ED where resources could be pulled in as needed to test our assumption that DKA patients could be effectively cared for outside of the ICU.
The temporary unit was staffed with floor nurses, on-call ICU nurses, and various other resources. In just the first case, the team identified unnecessary resources, such as the ICU-level nurse, and validated a safe care approach for non-ICU floors.