A Comprehensive System for Identifying Patients With Type 1 Diabetes at Increased Risk for Diabetic Ketoacidosis at Texas Children’s Hospital David D. Schwartz, 1 Mili Vakharia, 2 Serife Uysal, 2 Kristen R. Hendrix, 2,3 Kelly Fegan-Bohm, 2 Sarah K. Lyons, 2 Rona Sonabend, 2 Sheila K. Gunn, 2 Rosa Banuelos, 4 and Selorm Dei-Tutu 2 Quality Improvement Success Stories are published by the American Diabetes Association in collaboration with the American College of Physicians and the National Dia- betes Education Program. This series is intended to high- light best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes a project at Texas Children’s Hospital aimed at improving identification of patients with type 1 diabetes at high risk for diabetic ketoacidosis. Describe your practice setting and location. Texas Children’s Hospital, located in Houston, TX, is the largest pediatric hospital in the United States, with 973 inpatient beds and extensive outpatient clinics and serv- ices. It is the primary pediatric teaching hospital of Baylor College of Medicine. The Texas Children’s Endo- crine and Diabetes Care Center is one of the largest pediatric endocrinology and diabetes centers in the country, with three inpatient facilities and seven ambu- latory clinics. The service is staffed by a multidisciplin- ary team that includes endocrinologists, endocrine fellows, advanced practice providers, certified diabetes care and education specialists (CDCESs), dietitians, social workers, and consulting psychologists. Almost 500 youth with newly diagnosed type 1 diabetes are admitted to the hospital each year, with a total pediatric diabetes population of >3,400 patients. Describe the specific quality gap addressed through the initiative. Diabetic ketoacidosis (DKA) is an acute, severe, and preventable complication of diabetes that can result in significant morbidity and mortality. The most common cause of DKA in children and adolescents with estab- lished type 1 diabetes is inadvertent or deliberate insu- lin omission, often occurring in the context of chronically poor glycemic control. Identifying risk fac- tors for diabetes-related morbidities is crucial to inform preventive efforts and target services to the patients in greatest need, with the ultimate goal of reducing the incidence of DKA. Before the start of this project, our hospital had no structured, formal way to identify patients with type 1 diabetes at greatest risk for poor glycemic control and DKA. Patients considered high risk might have been referred to social work or psychology staff by their dia- betes care providers, but this was a hit-or-miss process, with many patients likely being missed. More com- monly, patients would only be referred after experienc- ing one or more episodes of DKA. The care of these patients was therefore mostly reactive, resulting in increased morbidity and hospitalizations and incurring significant expense. To reduce complications and 1 Section of Psychology, Department of Pediatrics, Baylor College of Medicine, Houston, TX; 2 Section of Pediatric Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Houston, TX; 3 Piedmont Physicians Endocrinology, Columbus, GA; 4 Texas Children’s Hospital Quality Outcomes and Analytics, Houston, TX Corresponding author: David D. Schwartz, ddschwar@bcm.edu This series is published by the American Diabetes Association in collaboration with the American College of Physicians, Inc., and the National Diabetes Education Program. The American College of Physicians and the American College of Physicians logos are trademarks or registered trademarks of American College of Physicians, Inc., in the United States and shall not be used otherwise by any third party without the prior express written consent of the American College of Physicians, Inc. Likewise, products and materials that are not developed by or in partnership with the National Diabetes Education Program are prohibited from using the National Diabetes Education Program logo. This article contains supplementary material online at https://doi.org/10.2337/figshare.16776247 https://doi.org/10.2337/cd21-0072 ©2022 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. More information is available at https://diabetesjournals.org/journals/pages/license. 92 DIABETESJOURNALS.ORG/CLINICAL QUALITY IMPROVEMENT SUCCESS STORY Downloaded from http://diabetesjournals.org/clinical/article-pdf/40/1/92/638744/diaclincd210072.pdf by guest on 17 August 2022