New SQuID Game? SQ Insulin, DKA, and Length of Stay

Written by Laura Murphy

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The use of a subcutaneous insulin protocol for mild-to-moderate diabetic ketoacidosis (DKA) resulted in significant reductions in ED LOS.

Why does this matter?
With emergency departments across the country experiencing record levels of overcrowding and boarding, considering alternative treatment pathways that can improve operational metrics has become increasingly important.

A little ink on the SQuID protocol
There have been multiple studies demonstrating that use of subcutaneous insulin for treatment of mild to moderate DKA in non-ICU settings is a safe and cost-effective alternative to intravenous insulin infusions. This study focused on the impact of subcutaneous insulin use on ED length-of-stay (ED LOS).

This was a prospectively derived single center, pre-post study which included patients with hyperglycemia, positive ketone test and presence of an anion gap and excluded patients with pH<7.0, HCO3<10 mmol/L.  The SQuID (subcutaneous insulin in DKA) treated patients with fast-acting subcutaneous insulin based on blood glucose values (rather than insulin infusion), with fingerstick glucose testing every 2 hours. The protocol excluded the following patients: less than 18 years, pregnant, concomitant serious infections, concerns for myocardial infarction, altered mental status, active comorbidities (e.g. ESRD, CHF, immunosuppression, need for surgery), or determined to be too ill for the inpatient observation unit that these patients were admitted to.

They enrolled 177 adult patients (78 subcutaneous protocol, 99 traditional cohort) in addition to retrospectively identified pre-intervention (163 patients) and pre-COVID (161 patients) historical controls from August 2021 to February 2022. There was excellent fidelity to the protocol and no statistically significant differences in safety between SQuID and traditional pathways, as measured by need for rescue dextrose (2.7% vs. 3.6%). Median ED length of stay (LOS) was significantly shorter for the SQuID cohort compared to control cohorts during post-intervention period (-3.0 hours, 95%CI -8.5 to -1.4), pre-intervention (-0.14 95%CI -3.1 to -0.1), and pre-COVID (-3.6 95%CI -7.5 to -1.8) periods. There were reductions in ICU admissions, but these were not statistically significant.

Limitations include a single-center study, which significantly limits generalizability, especially for operational parameters, which may vary significantly between sites. However, it does add to the evidence that treatment of mild-to-moderate DKA is a reasonable and safe treatment pathway for patients, and may have a positive impact on ED operational metrics in a time of increasingly constrained hospital resources.

Here was the SQuID protocol they used:

From cited article

Editor’s note: This protocol uses 0.45%NS and what appears to be significant D5W infusions. It seems this would cause hyponatremia, but sodium levels were not reported. The lead author (Dr. Griffey) confirmed that he did not recall significant problems with hyponatremia. He also confirmed that they start the SQuID protocol with a bolus of 1-2L of NS, just like the traditional DKA protocol (with IV insulin). I would think that as the glucose falls, they would add D5 1/2NS, not D5W, but maybe I am misunderstanding how the protocol is written. Overall, I like the idea of a subcutaneous insulin protocol for mild to moderate DKA and have experience with one that uses D5LR, but I wouldn’t feel comfortable using it exactly as it’s written above. ~Clay Smith

The SQuID Protocol (Subcutaneous Insulin in Diabetic Ketoacidosis): Impacts on ED Operational Metrics. Acad Emerg Med. 2023 Feb 12. doi: 10.1111/acem.14685. Online ahead of print.

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