Putting SQuID on the menu: A subcutaneous insulin protocol for diabetic ketoacidosis

Beginning in 2021, we developed and implemented the SQuID (subcutaneous insulin in diabetic ketoacidosis [DKA]) protocol for low to moderate severity (LTM) DKA, treating these patients on a single inpatient Hospitalist-run observation floor and demonstrating reductions in emergency department (ED) length of stay of over 3 h compared with LTM DKA patients treated in the ED with intravenous (IV) insulin and subsequently admitted to the medical floor. We expanded bed eligibility to a second Hospitalist-only floor from March 2023 to March 2024. We demonstrated equivalent safety and effectiveness of SQuID in LTM DKA compared with treatment on IV insulin, reducing intensive care unit (ICU) utilization for LTM DKA by over 33%, and maintaining high clinician acceptability ratings. Here we discuss lessons learned, keyinsights and pitfalls for the implementation of this innovation.