Appalachian Regional Healthcare

Reduces Time to DKA Resolution by 25% With Nurse-Driven Protocol in MEDITECH Expanse

Happy nurse working on tablet in office

Photo credit: Testing

Patients experiencing diabetic ketoacidosis, a life-threatening complication of diabetes, require complex, labor-intensive care. At Appalachian Regional Healthcare, emergency and intensive care nurses treating patients with DKA were required to contact physicians several times throughout the course of therapy for dose adjustments and medication supplementation.

“To improve the quality of care for these patients, a multidisciplinary team researched best practices to develop a new DKA protocol and built the workflow into our Expanse EHR,” said CIO Montie Hodge.

Lead IT Physician Bradley Moore, DO, a family practitioner, noted the evidence-based protocol has garnered a lot of support f rom ARH physicians.

“Patients spend fewer days in the ICU and less time on continuous insulin,” said Dr. Moore. “In addition, nurses aren’t calling physicians at home, in the middle of the night, nearly as often with questions about insulin adjustment and electrolyte replenishment.”

“Automating much of the process in Expanse helps nurses feel more empowered when caring for these high-acuity patients,” added Hodge.

Taking a multidisciplinary approach

After ARH clinicians found that basing DKA treatment solely on glucose levels was not enough, a multidisciplinary team of physicians, pharmacists, nurses, and IT analysts thoroughly researched DKA care guidelines to develop a new protocol. They collaborated on an evidence-based approach that treats acidosis and electrolyte imbalances in addition to controlling glucose.

Using MEDITECH’s Expanse Patient Care and Pharmacy solutions, the multidisciplinary team built the nurse-driven protocol into the system. ARH leadership chose to roll out the new protocol at three pilot sites.

“Our educators conducted in-person training with simulated DKA events,” said Director of IT Education Solutions Sabrina Hicks. “Nurses practiced using the DKA flowsheet with realistic-looking data, making titration decisions based on the protocol. The training went very well, as it enabled nurses to gain hands-on experience while building confidence.”

Here’s how the enhanced process works:

  • DKA protocol orders are preselected in the system.
  • Orders for appropriate maintenance fluids are reflexed using MEDITECH screens and rules to assess patient labs.
  • A DKA flowsheet, which includes the protocol, drives interventions throughout treatment.

New lab results indicate the need for electrolyte replacement and insulin titration. 

  • Sections that don’t apply, based on previously entered data, are grayed out.
  • The system suggests orders based on nurses’ documentation.

All 14 ARH facilities have been LIVE with the DKA protocol since July 2023.

Male nurse showing patient a tablet in hospital bed

Gauging the new protocol’s success

ARH pharmacists recently compared the previous protocol to the new protocol using data based on chart reviews of approximately 100 patient cases.

“The new DKA protocol takes about the same amount of time to reach a glucose level of less than 250 mg/dL. However, it reduces the amount of time to DKA resolution by approximately 25%,” said Clinical Pharmacy Informaticist Josh Vestal, PharmD.

Vestal noted that an added benefit of the protocol is its reduction of hypokalemic events, which he attributes to “the built-in monitoring of potassium and the protocol for potassium replacement.”

By using its Expanse EHR to guide the new DKA protocol, ARH has not only improved outcomes for its patients, but reduced the care team’s burden of treating a complex, life-threatening condition.

“The new protocol has drastically improved how we care for patients who are experiencing DKA,” said Dr. Moore. “Not only is it better for the patients, but it’s less stressful for the nurses, who are able to follow the protocol and manage the treatment effectively.”


Previous Protocol

Current Protocol

Time to DKA resolution

13.1 hours

9.8 hours

Hypokalemic events
(potassium level < 3.3 mEqL)