Diabetes and Vascular Disease

MON-655 - Subcutaneous Insulin Pathway for DKA Reduces ICU Admissions and Decreases Hypoglycemia in a Veterans Affairs Hospital

Monday, June 15, 2026

9:00 AM - 2:00 PM CT

Location: ENDOExpo; Poster Floor

Late-Breaking Poster Presenter(s)

CS

Caleb Victor Schmid, MD

Assistant Professor
Portland VA Medical Center
Portland, Oregon, United States

Senior Author/Primary Investigator(s)

CS

Caleb Victor Schmid, MD

Assistant Professor
Portland VA Medical Center
Portland, Oregon, United States
BM

Brian McGarry, MD

Clinical Fellow
University of California, Davis
Sacramento, California, United States

Co-Author(s)

DR

Doug Rice, MD

Assistant Professor
Oregon Health and Science University
Portland, Oregon, United States

Senior Author/Primary Investigator(s)

MD

Matthew DiVeronica, MD

Staff Attending/Clinical Hospitalist
Portland VA Medical Center
Portland, Oregon, United States

Co-Author(s)

BG

Brenda Grossnickle, MSN, APRN, CNS-PP, AGCNS-BC, CMSRN

Clinical Nurse Specialist
Portland VA Medical Center
Portland, Oregon, United States
JK

Jennifer Kime, MSN, APRN, ACCNS-AG, CCRN

Clinical Nurse Specialist
Portland VA Medical Center
Portland, Oregon, United States
SF

Stuti Fernandes, MD

Veterans Health Administration
Portland, United States
BH

Barbara Hettinger, MD, PhD

Endocrinology Section Chief and Endocrinology, Diabetes and Nutrition Fellowship Program Director
Portland VA Health Care System
Portland, Oregon, United States

Introduction &

Objective: Diabetic ketoacidosis (DKA) is traditionally managed with
intravenous insulin in the intensive care unit. Literature shows a subcutaneous insulin
(SQI) pathway for treatment of mild to moderate severity DKA on acute care wards is safe
and effective. We implemented a standardized SQI pathway to improve care for patients
with DKA at a 120-bed Veterans Affairs Hospital.

Methods: Our multidisciplinary team used a Lean Six Sigma approach to evaluate local
safety concerns in DKA care processes and guide iterative improvements. We developed
and implemented a treatment pathway for SQI for patients with mild to moderate DKA.
Primary outcomes were ICU admission and incidence of hypoglycemia (blood glucose ≤
70mg/dL).

Results: We analyzed DKA admissions prior to implementation (Jan 2017 to Aug 2024) and
after (Sep 2024 to Jan 2026). Pre-implementation, there were a total of 178 DKA
admissions, 124 to ICU and 54 to Acute Care. Post-implementation, there were a total
of 36 DKA admissions, 17 to ICU and 19 to Acute Care. The SQI intervention was
associated with an Odds Ratio of ICU admission for all-comers with DKA of 0.39, 95% CI
[0.19, 0.81]. Admissions with at least one episode of hypoglycemia decreased from 29% to
22% after implementation. There were no recorded hypoglycemic events in the 19 patients
admitted to acute care in the SQI pathway.

Conclusion: Implementation of a SQI pathway was associated with a reduction in
likelihood of ICU admission for DKA and in treatment-related hypoglycemic events in our
VA hospital.

*Unless otherwise noted, all abstracts presented at ENDO must not be released to the press or the public until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.*