Revolutionizing DKA Management in the ED: The SQuID Protocol’s Impact

Review Author: Thomas Leonard, MD

Introduction:

Managing diabetic ketoacidosis (DKA) in the emergency department (ED) has long been a challenge, often requiring intensive care unit (ICU) admission and leading to prolonged ED stays. However, a new study introduces the SQuID protocol (Subcutaneous Insulin in Diabetic Ketoacidosis)—a promising alternative that could streamline care and reduce ED overcrowding.

What is the SQuID Protocol?

The SQuID protocol replaces traditional IV insulin infusions with fast-acting subcutaneous (SQ) insulin analogs for patients with mild-to-moderate (MTM) DKA. This shift allows appropriate patients to be treated in non-ICU settings, reducing ED length of stay (EDLOS) and potentially alleviating ICU bed shortages.

How Does the SQuID Protocol Work?

The SQuID protocol follows a structured approach for managing MTM-DKA patients safely outside the ICU:

1. Patient Selection Criteria

Inclusion Criteria:

• Adults with mild-to-moderate DKA

• Blood glucose > 300 mg/dL

• Positive ketones (≥1.1 mmol/L)

• Presence of anion gap metabolic acidosis

Exclusion Criteria:

• Severe DKA (HCO3 < 10 mmol/L or pH < 7.0)

• Pregnancy

• Concomitant serious infections

• Myocardial infarction concerns

• Altered mental status

• Active end-stage renal disease, CHF, or immunosuppressive therapy

• Need for surgical intervention

  
  

**Patients meeting exclusion criteria default to the traditional IV insulin infusion pathway.

2. SQuID Insulin Administration

• Initial Treatment:

  • SQ fast-acting insulin (lispro/aspart) 0.3 units/kg as a bolus

  • Repeat SQ insulin every 2 hours based on blood glucose levels

• Ongoing Monitoring:

  • Every 2-hour glucose checks

  • Fluid resuscitation with normal saline (NS) bolus 2L, then maintenance fluids

  • Electrolyte monitoring, rechecking potassium every 4 hours

• Transition to Basal Insulin:

  • Long-acting insulin (glargine or detemir) given within 2 hours of starting SQuID

  • Patients discharged on their usual insulin regimen

    
    

**Patients remain on this protocol in an inpatient observation unit, targeting discharge within 48 hours.

Key Findings from the Study

Comparison of the SQuID protocol to traditional insulin infusions in treating MTM-DKA found the following:

• Reduced ED Length of Stay – Patients treated with SQuID had significantly shorter ED stays compared to those receiving IV insulin.

• Equivalent Safety – No increased risk of hypoglycemia or need for rescue dextrose.

• Potential to Reduce ICU Admissions – ICU admissions trended lower for MTM-DKA patients after implementing SQuID.

• High Protocol Adherence – Providers and nurses followed the protocol effectively, demonstrating its feasibility in real-world ED settings.

Why This Matters

With ICU bed shortages and ED crowding becoming increasingly common, the SQuID protocol offers a viable alternative to traditional DKA management. By safely treating select DKA patients outside of the ICU, hospitals can free up critical care resources while maintaining high-quality patient care.

The Future of DKA Management

This study lays the groundwork for broader adoption of SQ insulin protocols in emergency medicine. With further validation and implementation, the SQuID protocol could become a new standard of care, improving efficiency without compromising safety.

Reference:

Griffey RT, Schneider RM, Girardi M, Yeary J, McCammon C, Frawley L, Ancona R, Cruz-Bravo P. The SQuID protocol (subcutaneous insulin in diabetic ketoacidosis): Impacts on ED operational metrics. Acad Emerg Med. 2023 Aug;30(8):800-808. doi: 10.1111/acem.14685. Epub 2023 Feb 27. PMID: 36775281.

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