Interprofessional, multiple step simulation course improves pediatric resident and nursing staff management of pediatric patients with diabetic ketoacidosis

Table 1 Demographic and test questions

Demographic information
1 What year in residency are you?
PGY1 PGY2 PGY3 PGY4
2 Circle the residency program you are currently enrolled in.
Pediatrics Med-Peds Emergency medicine
3 Have you done an endocrine rotation during your residency?
Yes No
(1) If yes, what year in your training did you do this rotation?
PGY1 PGY2 PGY3 PGY4
4 Do you personally have type 1 diabetes?
Yes No
(1) If yes, have you ever been treated for DKA?
Yes No
5 Have you ever actively cared for a family member or close friend with diabetes?
Yes No
6 Have you ever cared for a patient with DKA during your training?
Yes No
(1) If yes, what rotations did you take care of these patients? Please list the rotations
(2) Approximately how many patients have you cared with DKA
0-5 patients 5-10 patients 10-20 patients > 20 patients
Test questions (1correct answers, some questions have more than one answer) 1 Match the best words that define diabetic ketoacidosis (DKA) with the appropriate lab value
A Dehydration	(1) BS > 200 mg/dL1
B Ketosis1	(2) Bicarb < 19, Ph < 7.35
C Acidosis1	(3) Urine or serum ketones1
D Polydipsia	(4) Bicarb < 15, pH < 7.31
E Vomiting	(5) Spec grav > 1.030
F Hyperglycemia1	(6) Glycosuria
2 Which of the following signs/symptoms best describes a patient with DKA?
A Vomiting/diarrhea, hypokalemia
B Fever, leukocytosis
C Rapid deep breathing, altered mental status, vomiting, polyuria1
D Polyuria, polydipsia, nocturia
3 Which of the following is not a known complication that can occur during management of DKA?
A Cerebral Edema
B Hypokalemia
C Pancreatitis
D Hematuria1
E Rhabdomyolysis
F Hypercholermic metabolic acidosis
G Mucormycosis
4 Which of the following explanations best explains the best initial therapy for DKA after initial fluid resuscitation?
A Continuous IVF with 1/2NS or NS to replace fluid losses over 48 h, insulin gtt at 0.1 units/kg per hour1
B Continuous IVF with 1/2NS or NS to replace fluid losses over 48 h, insulin gtt at 0.05 units/kg per hour
C Maintenance IVF with 1/2NS or NS, insulin gtt at 0.1 units/kg per hour
D Maintenance IVF with 1/2NS or NS, IV insulin bolus followed by insulin gtt at 0.1 units/kg per hour
E Twice maintenance IVF with 1/2NS or NS, insulin gtt at 0.1 units/kg per hour
F Sodium bicarbonate administration, IV insulin bolus IV followed by insulin gtt at 0.1 units/kg per hour, maintenance fluids with 1/2NS or NS
5 What labs and how often should labs be drawn on a patient in DKA, including D-sticks?
A D-sticks Q1H, serum electrolytes Q4H
B D-sticks Q15 minutes, serum electrolytes Q2H
(1) D-sticks Q1H, serum electrolytes Q2H initially then Q4H once steady improvement is noted1
(2) D-sticks Q1H, serum electrolytes Q2H twice, then Q6H once steady improvement is noted
6 When should the patient’s neurological status be assessed?
A On admission, every hour during treatment, as needed for acute changes1
B Every hour during treatment
C On admission, every hour for the first four hours of treatment and then as needed for acute changes
D On admission and as needed for acute changes
7 When should dextrose be added to your treatment of DKA?
A When blood sugar drops by more than 100 mg/dL in an hour
B When blood sugar is less than or equal to 250 mg/dL
C When blood sugar drops by more than 75 mg/dL in an hour
D When blood sugar is less than or equal to 300 mg/dL
E A and B
F A and D1
G C and D
H B and C
8 When should potassium not be added to the IVF?
A When potassium is < 5.5
B When patient has urinated
C When no EKG abnormalities are noted on cardiac monitor
D When patient has evidence of acute renal failure on lab evaluation1
9 Identify three signs/symptoms of cerebral edema
A Headache1
B Altered mental status1
C Hyperactivity
D Hypotension
E Bradycardia1
F Tachycardia
10 Over what period of time should you correct a patient in DKA’s dehydration?
A Immediately
B Over 12 h
C Over 24 h
D Over 48 h1
E Over 72 h
11 When is the patient at the greatest risk for developing cerebral edema?
A On admission/before treatment
B At initiation of treatment
C Several hours into treatment1
D At the time of transition
12 Describe the process of how to transition a patient off an insulin drip onto SQ insulin (Do not need to describe calculating doses of insulin. Just the basic process)
A Order food tray, when food arrives, administer long acting insulin and mealtime SQ insulin, allow patient to eat, approximately one hour later discontinue the insulin gtt, and remove dextrose from fluids1
B Discontinue insulin gtt, administer long acting insulin when arrives
C Administer long acting SQ insulin, one hour later allow patient to eat and administer mealtime insulin, discontinue insulin gtt, remove dextrose from fluids
D Order food tray, when food arrives, allow patient to eat, administer long acting insulin and mealtime SQ insulin, approximately one hour later discontinue the insulin gtt
13 When should the insulin drip be stopped during the treatment of DKA?
A When the blood sugar drops by > 200 mg/dL
B During transport
C When the bicarb is 19
D When long acting SQ insulin has been given in consultation with endocrine1
14 Which of the following therapies is appropriate treatment of DKA?
A Bicarb administration
B Several hour delay or interruption in receiving insulin gtt
C Rapid drop in glucose during treatment
D Multiple fluid boluses at the beginning of treatment unless patient is hemodynamically unstable
E Starting the insulin drip one hour after IV fluid hydration has been initiated1
15 On a scale from 1 to 5, how beneficial did you find the simulation exercise?
1 2 3 4 5
Least helpful Most helpful
16 How would you improve this simulation exercise? (add this to the immediate post-test and not the one done at 3-6 mo)

¹Correct answer.

Table 2 Demographic Information for Control and Intervention Groups n (%)

Category	Control Group (n = 16)	Intervention Group (n = 20)	P value
Residency training year			0.003
PGY 2	0 (0)	8 (40)
PGY 3/4	16 (100)	12 (60)
Type of residency			0.192
Pediatric	13 (81)	19 (95)
Medicine-pediatric	3 (19)	1 (5)
Treated DKA in residency	16 (100)	20 (100)	0.192
Endocrine rotation only	2 (13)	4 (20)
ICU rotation only	5 (31)	1 (5)
Both endocrine and ICU rotation	6 (37)	9 (45)
Other (ED, night float)	3 (19)	6 (30)
Estimated number of patients treated with DKA			0.825
1-10	2 (13)	4 (20)
10-20	8 (50)	9 (45)
> 20	6 (37)	7 (35)

PGY: Post graduate year; DKA: Diabetic ketoacidosis; ICU: Intensive care unit; ED: Emergency department.