Abstract
Objectives
Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 diabetes (T1D). The aim of this study is to analyze the incidence, clinical characteristics, management ...and outcome of children presenting with DKA in new-onset T1D from 2008 to 2018 in Hong Kong.
Methods
Data was extracted from the Hong Kong Childhood Diabetes Registry. All subjects less than 18 years with newly diagnosed T1D from 1 January 2008 to 31 December 2018 managed in the public hospitals were included. Information on demographics, laboratory parameters, DKA-related complications and management were analyzed.
Results
In the study period, there were 556 children with newly diagnosed T1D in our registry and 43.3% presented with DKA. The crude incidence rate of new-onset T1D with DKA was 1.79 per 100,000 persons/year (CI: 1.56–2.04). Subjects presenting with DKA were younger (9.5 ± 4.5 vs. 10.5 ± 4.4, p=0.01) and had shorter duration of symptoms (4.2 ± 5.9 days vs. 10.6 ± 17.1 days, p<0.01). Regarding management, up to 12.4% were given insulin boluses and 82.6% were started on insulin infusion 1 h after fluid resuscitation. The rate of cerebral edema was 0.8% and there was no mortality.
Conclusions
Younger age and shorter duration of symptoms were associated with DKA in new-onset T1D. Despite availability of international guidelines, there was inconsistency in acute DKA management. These call for a need to raise public awareness on childhood diabetes as well as standardization of practice in management of pediatric DKA in Hong Kong.
Obesity and type 2 diabetes mellitus (T2DM) are growing health concerns. Since 2005, Student Health Service (SHS) and Hong Kong Paediatric Society formulated a protocol on urine glucose screening ...(UGS) for early diagnosis of T2DM in students with obesity in Hong Kong. This study reviews students with T2DM captured by this screening program and compare the data with the Hong Kong Children Diabetes Registry (HKCDR) database, to see if the UGS program facilitates early diagnosis of T2DM.
Students between the ages of 10-18 years old with age- and sex-specific body mass index (BMI) >97th percentile who attended SHS between the school years from 2005/06 to 2017/18 were recruited for UGS. Those tested positive for random urine glucose underwent diagnostic testing for T2DM according to ADA guidelines. Demographic data and investigatory results from UGS and HKCDR within the same time period were compared.
A total of 216,526 students completed UGS in the said period; 415 (0.19 %) students were tested positive for urine glucose of which 121 students were diagnosed with T2DM. UGS picked up 23 % of the newly diagnosed T2DM cases. When compared to the HKCDR database, students diagnosed via UGS were significantly younger, less obese, and had fewer diabetic related complications. The negative predictive value of UGS is high and can effectively rule out T2DM.
Urine glucose screening is an inexpensive and simple test that allows for early diagnosis of T2DM among obese school students. Other methods including POCT HbA
can be explored to improve program effectiveness.
Introduction
Chemotherapy is a dynamic, complex process involving cross-functional healthcare teams and comprises dosing, scheduling, safety checks, compounding and administration. Coupled with team ...silos, legacy systems, escalating workload and cost, efficient chemotherapy delivery is increasingly challenging, resulting in negative staff and patient experience. A design thinking methodology focused on end-users is ideal for addressing complex problems with no clear best practices.
Aim
We hypothesized that a multidisciplinary team using a data-driven, design thinking approach to redesign chemotherapy workflows can reduce time to treatment, improve operational efficiency and staff and patient experience.
Methods
A process mapping exercise was undertaken to understand the chemotherapy process. Patients and staff from different job groups were shadowed. The problem statement was “60% of patients are waiting more than an hour from their appointment time to start treatment”. The following examples of “how might we” questions were used for the ideation phase:
1. How might we increase advanced chemotherapy preparations (premakes) for patients?
2. How might we ensure only premakes are listed in the mornings?
Separately, we also designed an anonymized database to track chemotherapy delivery and care provision outcomes by writing an algorithm to link data extracted from appointment, queue management and chemotherapy systems. New workflows were drafted, iterated, and implemented from 1 May 2020 with the following major changes:
1. No same day blood tests and chemotherapy, with physicians reminded to complete chemotherapy orders by 3pm the day before to allow advance compounding.
2. All chemotherapy regimens were consolidated into a directory containing properties like infusion duration, premake eligibility (based on drug stability and cost) and other scheduling characteristics. This was made searchable via an Excel (Microsoft, USA) algorithm, which also recommended ideal booking slots for the scheduling team. Premakes were prioritized for morning (0830 - 1030) slots.
3. Outcome targets were agreed on and tracked daily. These were made accessible to all staff via a dashboard. The workgroup met weekly to discuss targets, barriers and iterate workflows. Daily, intra-group communication was facilitated by TigerConnect (TigerConnect, USA).
We included consecutive outpatients treated at our institution from 1 Jan - 27 Jul 2020. Patients were split into two groups: a historical control group (1 Jan - 30 Apr) and a post-intervention study group (1 May - 27 Jul).
The primary outcome measure was the difference between appointment time and time treatment started. Secondary outcome measures included (a) proportion of premade chemotherapy; (b) number of patients starting treatment within an hour of appointment time; and (c) number of patients finishing treatment after 6pm.
Continuous data are reported as median (25th-75th centile) and analysed with the Mann-Whitney U test, while categorical data were assessed with the chi-square test. Analysis was done with SPSS v22 (IBM, USA).
Results
Results are summarized in Table 1. From 1 Jan - 27 July 2020, 14314 treatments were completed. Of these, 5946 (41.5%) were in the 0830 - 1030 slots prioritized for premade chemotherapy. 18.8% of patients arrived after their appointment time. The proportion of premade chemotherapy increased to 70.8% from 30.6% (p<0.001).
The median time to start treatment decreased from 83 (51-128) minutes in the control to 49 (27-87) minutes in the study group (p<0.001). This translated into an improvement for the day overall (Figure 1).
The proportion of patients with morning appointments starting treatment within 1 hour of their appointment time increased to 58.4% from 31.7% (p<0.001). For the whole day, this increased to 59.6% from 37.8% (p<0.001), resulting in less patients finishing treatment after 6pm (20.5% to 10.6%, p<0.001).
Conclusion
We have shown that a multidisciplinary group using a data-driven, design thinking approach to address team silos, reorganize and track work processes can improve the time taken to start treatment. Changes were made at no added cost to the healthcare system and using accessible software. Potential cost savings in terms of less overtime claims for staff have yet to be factored in. Addressing patient punctuality and registration and triage processes will help further decrease time to treatment.
Display omitted
No relevant conflicts of interest to declare.
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