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Hospitalizations for Diabetic Ketoacidosis -- Washington State, 1987-1989

Diabetic ketoacidosis (DKA) is an acute metabolic complication of diabetes mellitus that can be life threatening. Although DKA is often preventable (1-3), approximately 84,000 DKA-associated hospitalizations and 1800 DKA-associated deaths occurred in the United States during 1988 (4). The Washington Department of Health (WDH) monitors DKA-associated hospitalizations to assist its chronic disease programs in preventing DKA-associated hospitalizations and deaths. This report summarizes surveillance of DKA hospitalizations among Washington state residents from 1987 through 1989.

The analysis included all hospitalizations * in Washington except those from Veterans Administration, military, and psychiatric facilities. The hospitalizations included any patient for whom DKA (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM], diagnosis code 250.1) was recorded on state hospital discharge records. Estimates of the number of persons with diabetes were calculated by applying 1988 estimates of diabetes prevalence from CDC's National Health Interview Survey to Washington population estimates for 1987-1989.

During 1987-1989, 4377 DKA-associated hospitalizations occurred among Washington residents. Although the statewide DKA-associated hospitalization incidence rate for the 3-year period was 12.5 per 1000 persons with diabetes, rates by county of residence ranged from 7.3 to 27.9 per 1000.

Rates also varied by age and sex. Rates were higher for younger persons; persons aged 0-44 years accounted for 72% of all admissions for DKA. Within this age group, rates were substantially higher for females (61.2 per 1000) than for males (42.5 per 1000) (Figure 1).

More than one third (36%) of DKA-associated hospitalizations occurred among persons who had at least one other admission for DKA during the 3-year period; persons aged less than 45 years accounted for nearly half (45%) of these repeat admissions.

Persons with diabetes who were hospitalized for DKA were more likely to receive Medicaid (27%) than were persons with diabetes hospitalized for all causes, including DKA (10%). Younger persons (i.e., those aged less than 45 years) and persons with repeat admissions were also more likely to receive Medicaid. Thirty-three percent of persons aged less than 45 years and 30% of persons who had repeat admissions used Medicaid to cover the cost of hospitalization. In contrast, only 10% of those aged greater than or equal to 45 years and 15% of persons admitted only once during the 3-year period received Medicaid.

Reported by: C Shaw, MPH, Washington Dept of Health. Div of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: Manifestations of DKA include acute or subacute alteration of mental state, fatigue, weight loss, blurred vision, thirst, excessive urination, enuresis, abdominal pain, nausea, and vomiting. DKA may occur in persons with insulin-dependent diabetes mellitus (IDDM) who have new onset of disease, who do not take insulin, or who do not increase their insulin dosage during illness. Among persons with noninsulin-dependent diabetes mellitus (NIDDM), DKA may be associated with severe acute stress (e.g., pneumonia or myocardial infarction).

Basic considerations for prevention of DKA are for both patients and health-care providers to 1) recognize that certain persons with diabetes (e.g., those with psychosocial or major emotional problems, adolescents, and those with physical illnesses) may have difficulty adhering to a prescribed program of insulin therapy and dietary control, 2) recognize indicators of inappropriate therapy, and 3) be knowledgeable about proper techniques for monitoring and management of diabetes (3). Although all persons with diabetes should be taught to monitor their blood glucose levels, those at increased risk for DKA should receive intensified instruction that emphasizes the importance of such monitoring. In addition, persons with diabetes should monitor ketones in their urine when their blood glucose level is 240 mg/dL or higher and/or acute illness develops (3). Persons with diabetes should understand the importance of contacting their health-care providers immediately if their blood glucose level remains higher than 240 mg/dL, ketonuria develops, or symptoms of illness persist. Persons with diabetes should use guidelines for self-care (5); health-care providers should use guidelines for the clinical management of DKA (6).

In addition to treating an episode of DKA, health-care providers should analyze antecedent or precipitating circumstances and take measures to prevent further episodes. The analysis should include assessment of the patient's self-care practices, precipitating illnesses, stressful life events, and behavioral or emotional problems. Referral to endocrinologists, psychosocial specialists, or both may be appropriate for patients having particular difficulty in management of IDDM (3).

Public health strategies may also assist in preventing the occurrence of DKA-associated hospitalizations and deaths. For example, state and county surveillance data, such as those developed by the WDH, assist public health practitioners and health-care providers in directing services toward populations with the greatest need. Ensuring availability of preventive diabetes education and access to health care are also important factors in reducing the burden associated with DKA.

The Washington Diabetes Control Program (WDCP) provides educational materials and technical assistance to community health centers and hospitals. The analysis in this report indicates that such resources can be directed toward counties in which rates of DKA are high and especially toward younger persons (i.e., those aged less than 45 years) and Medicaid recipients with diabetes. As a result of this analysis, the WDCP and the state Medicaid office are exploring a pilot project to target Medicaid beneficiaries hospitalized with DKA for intensive education and follow-up by chronic disease case managers.


  1. Clements RS, Vourganti B. Fatal diabetic ketoacidosis: major causes and approaches to their prevention. Diabetes Care 1978;1:314-23.

  2. Schade DS, Eaton RP. Prevention of diabetic ketoacidosis. JAMA 1979;242:2455-8.

  3. CDC. The prevention and treatment of complications of diabetes: a guide for primary care practitioners. Atlanta: US Department of Health and Human Services, Public Health Service, 1991.

  4. CDC. Diabetes surveillance, 1991. Atlanta: US Department of Health and Human Services, Public Health Service, 1992.

  5. CDC. Take charge of your diabetes: a guide for care. Atlanta: US Department of Health and Human Services, Public Health Service, 1991.

  6. American Diabetes Association. Physician's guide to insulin-dependent (type I) diabetes: diagnosis and treatment. Alexandria, Virginia: American Diabetes Association, 1988.

    • Includes multiple admissions for some patients.

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