Selected Topics: Critical Care| Volume 58, ISSUE 4, P620-626, April 2020

An Emergency Department–Based Intensive Care Unit is Associated with Decreased Hospital and Intensive Care Unit Utilization for Diabetic Ketoacidosis

Published:December 13, 2019DOI:



      Many emergency department (ED) patients in diabetic ketoacidosis (DKA) are admitted to an inpatient intensive care unit (ICU), while ICU capacity is under increasing strain. The Emergency Critical Care Center (EC3), a hybrid ED-ICU setting, opened with the goal of providing rapid initiation of ICU care in the ED.


      We sought to evaluate the impact of an ED-ICU on disposition and safety outcomes for adult ED patients in DKA.


      This was a retrospective pre–post cohort of ED visits from 2012–2018 at a single academic medical center. Adult ED patients in DKA (pH < 7.30, HCO3 < 18 mEq/L, anion gap > 14, and glucose > 250 mg/dL) immediately before (pre-EC3) and after (post-EC3) opening of an ED-ICU were identified. ED disposition and safety data were collected and analyzed.


      We identified 631 patient encounters: 217 pre-EC3 and 414 post-EC3. Baseline demographics were similar between cohorts. Fewer patients in the post-EC3 cohort were admitted to an ICU (11.6% vs. 23.5%, p < 0.001, number needed to treat [NNT] = 8) or general floor bed (58.0% vs. 73.3%, p < 0.001, NNT = 6), and more were discharged from the ED (27.1% vs. 1.4%, p < 0.001, NNT = 4). Rates of hypokalemia (10.1% vs. 6.0%, p = 0.08) and admission to non-ICU with transfer to ICU within 24 h (0.5% vs. 0%, p = 0.30) did not differ.


      Management of patients with DKA in an ED-ICU was associated with decreased ICU and hospital utilization with similar safety outcomes. Managing rapidly reversible critical illnesses in an ED-ICU may help obviate increasing strain facing many health care systems.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Benoit S.R.
        • Zhang Y.
        • Geiss L.S.
        • Gregg E.W.
        • Albright A.
        Trends in diabetic ketoacidosis hospitalizations and in-hospital mortality — United States, 2000–2014.
        MMWR Morb Mortal Wkly Rep. 2018; 67: 362-365
        • Kitabchi A.E.
        • Umpierrez G.E.
        • Miles J.M.
        • Fisher J.N.
        Hyperglycemic crises in adult patients with diabetes.
        Diabetes Care. 2009; 32: 1335-1343
        • Hall M.J.
        • DeFrances C.J.
        • Williams S.N.
        • Golosinskiy A.
        • Schwartzman A.
        National Hospital Discharge Survey: 2007 summary.
        Natl Health Stat Rep. 2010; 29 (1–20, 24)
        • Kim S.
        Burden of hospitalizations primarily due to uncontrolled diabetes: implications of inadequate primary health care in the United States.
        Diabetes Care. 2007; 30: 1281-1282
        • Maldonado M.R.
        • Chong E.R.
        • Oehl M.A.
        • Balasubramanyam A.
        Economic impact of diabetic ketoacidosis in a multiethnic indigent population: analysis of costs based on the precipitating cause.
        Diabetes Care. 2003; 26: 1265-1269
        • Alsamman M.A.
        • Alsamman S.
        • Moustafa A.
        • Khan M.S.
        • Steinbrunner J.
        • Koselka H.
        Critical care utilization in patients with diabetic ketoacidosis, stroke, and gastrointestinal bleed: two hospitals experience.
        Cureus. 2019; 11: e4698
        • Gershengorn H.B.
        • Iwashyna T.J.
        • Cooke C.R.
        • Scales D.C.
        • Kahn J.M.
        • Wunsch H.
        Variation in use of intensive care for adults with diabetic ketoacidosis.
        Crit Care Med. 2012; 40: 2009-2015
        • Bull S.V.
        • Douglas I.S.
        • Foster M.
        • Albert R.K.
        Mandatory protocol for treating adult patients with diabetic ketoacidosis decreases intensive care unit and hospital lengths of stay: results of a nonrandomized trial.
        Crit Care Med. 2007; 35: 41-46
        • Zhou V.L.
        • Shofer F.S.
        • Desai N.G.
        • et al.
        Predictors of short intensive care unit stay for patients with diabetic ketoacidosis using a novel emergency department-based resuscitation and critical care unit.
        J Emerg Med. 2019; 56: 127-134
        • Herring A.A.
        • Ginde A.A.
        • Fahimi J.
        • et al.
        Increasing critical care admissions from U.S. emergency departments, 2001-2009.
        Crit Care Med. 2013; 41: 1197-1204
        • Haas N.L.
        • Gianchandani R.Y.
        • Gunnerson K.J.
        • et al.
        The two-bag method for treatment of diabetic ketoacidosis in adults.
        J Emerg Med. 2018; 54: 593-599
        • Gunnerson K.J.
        • Bassin B.S.
        • Havey R.A.
        • et al.
        Association of an emergency department–based intensive care unit with survival and inpatient intensive care unit admissions.
        JAMA Netw Open. 2019; 2: e197584
        • von Elm E.
        • Altman D.G.
        • Egger M.
        • et al.
        The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.
        J Clin Epidemiol. 2008; 61: 344-349
        • Quan H.
        • Li B.
        • Couris C.M.
        • et al.
        Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries.
        Am J Epidemiol. 2011; 173: 676-682
        • Kardalas E.
        • Paschou S.A.
        • Anagnostis P.
        • Muscogiuri G.
        • Siasos G.
        • Vryonidou A.
        Hypokalemia: a clinical update.
        Endocr Connect. 2018; 7: R135-R146
        • Chittineni C.
        • Driver B.E.
        • Halverson M.
        • et al.
        Incidence and causes of iatrogenic hypoglycemia in the emergency department.
        West J Emerg Med. 2019; 20: 833-837
        • Kitabchi A.E.
        • Sacks H.S.
        • Fisher J.N.
        Clinical trials in diabetic ketoacidosis.
        in: Larner J. Methods in diabetes research. John Wiley, New York1986: 315-332
        • Kitabchi A.E.
        • Materi R.
        • Murphy M.B.
        Optimal insulin delivery in diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar nonketotic coma (HHNC).
        Diabetes Care. 1981; 5: 78-87