Fellow Seattle Children's Hospital Seattle Children's Hospital Seattle, Washington, United States
Background: More severe presentations of diabetic ketoacidosis (DKA) have been reported during the COVID-19 pandemic (COVID), possibly due to avoidance of healthcare settings and/or reduced access to care. To date, no studies have utilized statistical process control (SPC) to relate temporal COVID events with DKA severity.
Objective: (1) To determine whether the severity of pediatric DKA presentations changed during COVID and (2) to temporally relate changes in severity with regional pandemic events.
Design/Methods: This was a retrospective chart review of 175 patients <18 years with DKA presenting to a pediatric emergency department in the United States between 5/1/2019 and 8/15/2020. SPC was utilized to analyze DKA severity measures, including presenting pH, proportion of PICU admissions, presenting glucose, and admission length of stay (LOS).
Results: During COVID,we found special cause variation with a downward shift in the mean pH on DKA presentation from 7.2 to 7.1 for all patients (Figure 1), with a similar shift in newly diagnosed patients. The proportion of DKA patients requiring PICU admission increased from 34.2% to 54.6%(Figure 2). Changes temporally corresponded to the statewide bans on large events (3/11/2020) and school closures (3/13/2020) and a reduction in our institution’s ED volumes, with a subsequent trend towards baseline in July 2020. Presenting glucose and admission LOS were unchanged. Conclusion(s): Pediatric DKA presentations were more severe from March to June 2020, correlating with regional COVID events. Ongoing work is needed to identify populations at risk of delayed presentations and to implement interventions targeting increased access to timely care for emergent conditions.
Figure 1. Xbar-S Chart: Mean and standard deviation of presenting pH for DKA patients. The average biweekly presenting pH of DKA patients was plotted on the upper panel from May 1,2019-August 15,2020. The corresponding standard deviation is plotted below. Key regional events in the COVID-19 pandemic are annotated. Criteria for special cause variation are noted starting 3/4/2020-3/17/2020.
Figure 2. P chart: Proportion of DKA admissions requiring PICU care. The biweekly proportion of DKA admissions requiring PICU care is plotted between May 1,2019 through August 15,2020. Key regional events in the COVID-19 pandemic are annotated. Criteria for special cause variation are noted starting 3/4/2020-3/17/2020.
Authors/Institutions: Kaileen Jafari, Seattle Children's Hospital, Seattle, Washington, United States; Ildiko Koves, Seattle Children's Hospital, Seattle, Washington, United States; Lori E. Rutman, Seattle Children's Hospital, Seattle, Washington, United States; Julie C. Brown, Seattle Children's, Seattle, Washington, United States