Critical Path Network-Diabetic ketoacidosis path to automate standing orders

All but very sickest patients treated in outpatient setting

Joan Totka, RN, MSN, CDE, clinical nurse specialist and certified diabetes educator at Children's Hospital of Wisconsin in Milwaukee, says her diabetic ketoacidosis (DKA) pathway has been in continual revision since 1991. "Our original clinical path started out like any other, with chart reviews, trying to get a standard of care for practice," she explains. "The biggest changes, of course, were over the first couple of years, but there's always a little tweaking here and there."

Much care shifted to outpatient basis

The length of stay for diabetes patients at Children's Hospital had been four to seven days. Then the hospital got it down to about two and a half days for newly diagnosed patients and one and a half days for a known diabetic child. "Now that we take care of all but the very sickest on an outpatient basis, the average length of stay is typically one and a half days," says Totka. The pathway deals with trying to stabilize the patient over the first 24-48 hours; then the outpatient care kicks in.

"The biggest change in our clinical path is that we've revamped our outpatient program," she says. "The clinical path is almost like a cover letter that drives the standing orders, medical protocols, and the nursing teaching plans." Their original paths were several pages long — a whole documentation instrument with nursing interventions, medical orders, and so on. "[The DKA pathway is] more of a medical orders kind of path," she says. "The nursing intervention is choosing the right teaching path."

Eventually, this path will be computerized. "Soon, all the interventions on the path will be on a menu for the doctors to pick and choose from," Totka says. Computers will be placed throughout the hospital at the nursing stations.

But is it realistic to expect that physicians will follow this path, computerized or not? "Yes," she says. "When the doctors enter their orders, the plan will be in front of them. They will choose from the standard orders. Perhaps it's because we're a teaching hospital, but I've never had any trouble getting cooperation on the plan. Attend ings follow it because they helped develop it, and residents follow it because they like knowing what to do."

Her department is currently launching standard orders that go with the pathway. "The orders now are cumbersome, but they'll be easier once they're on-line," says Totka.

The newest revision of the plan is called "Diabetes Type I — Uncontrolled/DKA" because that's the only diagnosis that will put patients in the hospital today. (See pathway, p. 24.) "There isn't a clinical acute care path for stable, newly diagnosed kids because we don't hospitalize them," says Totka. "Whether patients are in DKA and you already know they have diabetes, or whether they are newly diagnosed and in DKA, the difference lies in what teaching plans you should choose, not what medical care they should receive."

For more information, contact Joan Totka, RN, MSN, CDE, Children's Hospital of Wisconsin, Milwaukee. Telephone: (414) 266-2867. E-mail: