August 2023 Pick of the Month

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SQuIDing for Efficiency

For centuries, emergency medicine faculty meetings around the country have resounded with the refrain “we need more nurses.” At the same meetings, faculty also receive the imperative to shorten length of stay and improve patient satisfaction. Within this context, the work by Griffey et al, The SQuID protocol (subcutaneous insulin in diabetic ketoacidosis): Impacts on ED operational metrics offers an incremental solution. 

With traditional treatment of intravenous insulin infusion, patients with diabetic ketoacidosis (DKA) require intensive nursing and pharmacist time and attention in the ED, and in most centers, admission to an intensive care unit (ICU). The latter can require days to happen. Therefore, a single DKA patient can disproportionately consume ED resources compared with other equally sick patients. The work by Griffey et al, provides a proof of concept for streamlining the management of mild to moderate DKA patients by using a subcutaneous insulin dosing protocol (see Figure 1A). (Of practical relevance, the definition of moderate DKA allowed entry of patients with a blood pH as low as 7.0 and a bicarbonate concentration of 10 mM.) The results showed no sign of harm and a benefit in terms of a modestly decreased ED length of stay. Only 5 of 78 patients treated with SQuID required ICU admission. 

The available data do not show any effect on overall “consumption” of health care professionals’ time, but the discussion implies that the workload was decreased: “Our project was met with a high degree of enthusiasm by ED providers.” Thus, the data show potential for SQuID to safely simplify the treatment of DKA with a benefit of reduced ED length of stay. And, possibly, a reduction of time spent repetitively talking about the same problems in faculty meetings for centuries to come.


Jeffrey A. Kline, MD


SQuID Protocol

Source: Kirsty Challen, BSc, MBChB, MRes, PhD, Lancashire Teaching Hospitals | AEM Editor of Infographics