American Journal of Nursing Research
ISSN (Print): 2378-5594 ISSN (Online): 2378-5586 Website: Editor-in-chief: Apply for this position
Open Access
Journal Browser
American Journal of Nursing Research. 2019, 7(4), 664-669
DOI: 10.12691/ajnr-7-4-28
Open AccessArticle

Barriers and Strategies of Implementing DKA Care Set in the Emergency Department within the Banner System as Perceived by Nurses

Hala Ibrahim Zaiton1, , Joyce Toriente Relloso2 and Edgar Gatioan Manood3

1Medical-Surgical Nursing Department, Faculty of Nursing, Zagazig University, Elsharkia Governorate Egypt

2Nursing Management, College of Nursing, Taibah University, Medina, Kingdom of Saudi Arabia

3Development Education, College of Nursing, Taibah University, Medina, Kingdom of Saudi Arabia

Pub. Date: June 24, 2019

Cite this paper:
Hala Ibrahim Zaiton, Joyce Toriente Relloso and Edgar Gatioan Manood. Barriers and Strategies of Implementing DKA Care Set in the Emergency Department within the Banner System as Perceived by Nurses. American Journal of Nursing Research. 2019; 7(4):664-669. doi: 10.12691/ajnr-7-4-28


There are different barriers and strategies for implementing diabetic ketoacidosis (DKA) care set in the emergency department (ED). However, there is limited research on DKA care set in the ED. The current research tries to determine the barriers and strategies of implementing diabetic ketoacidosis (DKA) care set within the Banner system as perceived by nurses in the ED. The study utilized a qualitative descriptive method using a semi-structured face-to-face interview. Twelve (12) nurses from the Emergency Room(ER) aged 24 to 48 were the participants of the study. The qualitative inductive content analysis revealed four (4) main categories and themes regarding participant’s perceptions about barriers of implementing the DK care set in E; these are; Knowledge, Experience and Competence in identifying cases of DKA, Communication, and Language. Findings demonstrate that it is essential that nurses should profound understanding of DKA to assess and distinguish its symptoms from other diseases. Hence, knowledge of DKA pathophysiology and competence to identify its symptoms is significant in delivering the appropriate management and care. The study posits that the identified barriers (knowledge, experience, and competence in identifying cases of DKA, communication, and language) significantly affect the success of implementing the DKA Care Set. A collaborative effort is significant in the care of DKA patient; therefore, there is a need for a nursing staff education and training to enhance protocol adherence of protocol throughout DKA.

diabetic ketoacidosis treatment of hyperglycemia in ER DKA management DKA guidelines DKA management algorithm

Creative CommonsThis work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit


[1]  Phillips, C., & Sinha, A, "Successful Management of diabetic ketoacidosis: an innovative protocol," Practical Diabetes, 35(2), 51-54. 2018.
[2]  National Diabetes Fact Sheet. Atlanta, "GA: Center for Disease Control and Prevention; 2011," Retrieved from [Accessed April 7, 2014].
[3]  Gosmanov A.R, Wall B.M, "Diabetic ketoacidosis. In: Bope ET, Kellerman RD, Editors," Conn’s Current Therapy. Philadelphia, PA : Elsevier Saunders. 2014, pp. 710–713.
[4]  Canadian Diabetes Association Clinical Practice Guidelines Expert Committee, "Clinical practice guidelines for the prevention and management of diabetes in Canada," Can J Diabetes. 2013; 37(suppl 1):S1-S212.
[5]  Center for Disease Control and Prevention, "National Emergency DepartmentSamples, Agency for Healthcare Research and Quality," Retrieved from, 2012.
[6]  Sheikh-Ali, M., Karon, B. S., Basu, A., Kudva, Y. C., Muller, L. A., Xu, J., ... & Miles, J. M, "Can serum β-hydroxybutyrate be used to diagnose diabetic ketoacidosis?, " Diabetes care, 2008, 31(4), 643-647.
[7]  Nyenwe, E. A., & Kitabchi, A. E, "Evidence- based management of hyperglycemic emergencies in diabetes mellitus," Diabetes research and clinical practice, 2011, 94(3), 340-351.
[8]  Lewis, R. B., & Maas, S. M, "QDA Miner 2.0: Mixed-model qualitative data analysis software. Field methods,"2007, 19(1), 87-108.
[9]  Chauvette, A., Schick-Makaroff, K., & Molzahn, A. E, "Open Data in Qualitative Research. International Journal of Qualitative Methods," 2019, 18, 1609406918823863.
[10]  Renders C. M, Valk G.D, Griffin S, Wagner E. H, Eijk J.T, Assendelft W.J, "Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings, "Cochrane Database Syst Rev CD001481, 2011
[11]  Centres for Medicare Medicaid Services, "Report to Congress: Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes: Phase II Final Report," Availableat:; 2001. Cited December 18, 2014.
[12]  Ersek, M., Kraybill, B. M., & Hansberry, J, "Investigating the educational needs of licensed nursing staff and certified nursing assistants in nursing homes regarding end-of-life care," American Journal of Hospice and Palliative Medicine®, 1999, 16(4), 573-582.
[13]  Kitabchi, A. E., Umpierrez, G. E., Miles, J. M., & Fisher, J. N, "Hyperglycemic crises in adult patients with diabetes," Diabetes care, 2009, 32(7), 1335-1343.
[14]  Kitabchi AE, Umpierrez GE, Murphy MB, Kreisberg RA, "Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association," Diabetes Care. 2006; 29(12): 2739-2748.
[15]  Savage MW, Dhatariya KK, Kilvert A, et al, "Joint British Diabetes Societies guideline for the management of diabetic ketoacidosis," Diabet Med. 2011; 28(5):508 515.
[16]  Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Goguen J, Gilbert J. "Hyperglycemic emergencies in adults," Can J Diabetes. 2013; 37(Suppl 1): S72-S76.
[17]  Bull SV, Douglas IS, Foster M, Albert RK. "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(1): 41-46.
[18]  Waller SL, Delaney S, Strachan MW, "Does an integrated care pathway enhance the management of diabetic ketoacidosis?," Diabet Med. 2007; 24(4): 359-363.
[19]  Hara JS, Rahbar AJ, Jeffres MN, Izuora KE. "Impact of a hyperglycemic crises Protocol," Endocr Pract. 2013; 19(6): 953-962.
[20]  Umpierrez GE, Cuervo R, Karabell A, Latif K, Freire AX, Kitabchi AE. "Treatment of diabetic ketoacidosis with subcutaneous insulin aspart," Diabetes Care. 2004; 27(8): 1873-1878.
[21]  Umpierrez GE, Latif K, Stoever J, et al. "Efficacy of subcutaneous insulin lispro versus continuous intravenous regular insulin for the treatment of patients with diabetic ketoacidosis," Am J Med. 2004;117(5): 291-296.
[22]  Wallace TM, Matthews DR,"Recent advances in the monitoring and management of diabetic ketoacidosis," QJM. 2004; 97(12): 773-780.
[23]  Solá E, Garzón S, García-Torres S, Cubells P, Morillas C, Hernández- Mijares A,"Management of diabetic ketoacidosis in a teaching hospital," Acta Diabetol. 2006; 43(4): 127-130.
[24]  Singh RK, Perros P, Frier BM. "Hospital management of diabetic ketoacidosis: are clinical guidelines implemented effectively?," Diabet Med. 1997;14(6):482-486.
[25] _2014_CHAP_11.pdf.
[26]  Maletkovic J, Drexler A. "Diabetic ketoacidosis and Hyperglycemic hyperosmolar state," Endocrinol Metab Clin North Am. 2013; 42(4): 677-695.
[27]  Roberts JS, Vavilala MS, Schenkman KA, Shaw D, Martin LD, Lam AM. "Cerebral hyperemia and impaired cerebral autoregulation associated with diabetic ketoacidosis in critically ill children," Crit Care Med. 2006; 34: 2217-23.
[28]  Tiwari LK, Jayashree M, Singhi S," Risk factors for cerebral edema in diabetic ketoacidosis in a developing country: Role of fluid refractory shock," Pediatr Crit Care Med. 2012; 13: e91 6.
[29]  Pesut, D. J, "Refective clinical reasoning in the development o f practical intelligence as a source of power," In L. C. Haynes, T. A. Boese & H. K. Butcher (Eds.), Nursing in contemporary society: Issues, trends, and transition to practice (pp. 146-162). Upper Saddle River, NJ: Pearson/Prentice Hall. 2004.
[30]  Okougha, M., & amp; Tilki, M, "Experience of overseas nurses: The potential for misunderstanding,"British Journal of Nursing, 2010, 19(2), 102-106.
[31]  Nailon RE," Nurses’ concerns and practices with using interpreters in the care of Latino patients in the emergency department," J Transcult Nurs. 2006 Apr; 17(2): 119-28.