ARE WE MONITORING THE DKA ACCORDING TO STANDARDS? A CLINICAL AUDIT OF MONITORING PRACTICES IN ADULTS WITH DKA AGAINST THE JBDS-IP-23

Abstract

Background

Diabetic ketoacidosis (DKA) is a potentially life-threatening metabolic emergency in which safe management depends not only on appropriate treatment but also on frequent and structured monitoring of the clinical and biochemical response. The Joint British Diabetes Societies for Inpatient Care (JBDS-IP) 2023 guideline provides clearly defined recommendations for monitoring glucose, ketones, acid-base status, electrolytes, clinical observations, fluid balance and urine output during DKA treatment. However, adherence to these monitoring standards may vary in routine clinical practice. This clinical audit assessed compliance with the JBDS-IP 2023 monitoring recommendations among adults with DKA managed in a General Medicine setting at Ayub Teaching Hospital, Abbottabad.

Methods

A retrospective clinical audit was conducted in the Medical B Unit of Ayub Teaching Hospital, Abbottabad, covering the period from 10 October 2024 to 10 March 2025. All eligible adults aged 18 years or older with documented DKA who were managed in the unit during the audit period and had sufficient clinical records for assessment were included. A structured audit proforma based on the JBDS-IP 2023 guideline was used to review the frequency and timing of capillary blood glucose, blood ketones where an appropriate bedside facility was available, venous pH/bicarbonate, potassium, plasma electrolytes, clinical observations, fluid balance and urine output. Compliance was defined according to whether the required monitoring was documented at the recommended frequency and timing. Data were analysed using descriptive statistics and reported as frequencies and percentages.

Results

A total of 44 adult DKA admissions met the eligibility criteria. Compliance varied considerably across the individual monitoring standards. Hourly capillary blood glucose monitoring was achieved in 24 (54.5%) episodes, while hourly blood ketone monitoring was achieved in 12 of 31 eligible episodes (38.7%). Venous pH/bicarbonate and potassium monitoring at approximately 60 minutes was compliant in 30 (68.2%) episodes and at approximately 2 hours in 27 (61.4%). Further two-hourly pH/bicarbonate and potassium monitoring during early treatment was achieved in 22 (50.0%) episodes, while four-hourly plasma electrolyte monitoring was achieved in 20 (45.5%). Regular clinical observations showed the highest compliance at 34 (77.3%), followed by adequate fluid-balance documentation in 29 (65.9%) and urine-output monitoring in 25 (56.8%) episodes. Overall, only 5 (11.4%) episodes met all applicable predefined monitoring criteria, while 14 (31.8%) met most criteria with at least one documented gap and 25 (56.8%) had multiple monitoring gaps.

Conclusion

This audit identified important gaps in adherence to recommended DKA monitoring standards in the audited General Medicine setting. Clinical observations were documented more consistently, whereas repeated biochemical monitoring, particularly blood ketones, continued two-hourly biochemical assessment and four-hourly electrolyte monitoring, showed lower compliance. The findings highlight the need for a more consistent and structured approach to DKA monitoring, supported by clear documentation, staff education and regular audit-feedback. A repeat audit using the same predefined criteria would be appropriate to assess improvement in monitoring practice.