Threshold-based compliance with diabetic ketoacidosis management protocols and its association with inpatient mortality: a retrospective single-centre study in a tertiary hospital in Karachi, Pakistan

Objectives The aim of this study was to evaluate protocol adherence and its impact on inpatient mortality in patients with diabetic ketoacidosis (DKA) at a tertiary hospital in Karachi. The major hypothesis was that adherence to the DKA protocol reduces inpatient mortality. Design This was a retrospective cohort study. Setting The study was conducted at the Aga Khan University Hospital (AKUH), Karachi, a tertiary care hospital in Pakistan. Participants The study included patients diagnosed with DKA and admitted to AKUH from 2017 to 2021. Eligibility criteria included patients aged 18 and older, excluding those with incomplete records or referred to other hospitals. Primary and secondary outcome measures The primary outcome was inpatient mortality. The analysis included Cox proportional hazards regression. Secondary outcome measures included predictors of mortality such as hypertension, intubation, tachycardia and elevated creatinine levels. Results Non-compliance with the DKA protocol (<70%) was associated with a significantly higher inpatient mortality rate (p=0.003). Survival analysis revealed a shorter median survival time for patients with <70% compliance (15 days versus 19 days, p<0.05). Multivariable analysis showed that non-compliance was an independent risk factor for adverse events (adjusted HR 1.37 (95% CI 1.01 to 1.86), p=0.04). Hypertension, intubation, tachycardia and elevated creatinine levels were significantly associated with increased mortality risk. Conclusions Adherence to the DKA protocol is crucial for reducing inpatient mortality and improving outcomes, especially in low- and middle-income countries. Ensuring at least 70% compliance is vital. Recommendations include continuous training for healthcare providers, adequate staffing and resource optimisation. Future research should focus on interventions to boost compliance and explore other factors affecting protocol adherence to further enhance patient care.