Emergency Department Boarding Is Associated With Delayed Resolution and Increased Mortality in Adults With Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) management is protocol-driven and requires timely insulin infusion, frequent laboratory monitoring, and nursing-intensive care, most often delivered in the intensive care unit (ICU). Emergency Department (ED) boarding is increasingly common and associated with delays in care and worse outcomes in critically ill patients. The impact of ED boarding on DKA resolution and clinical outcomes has not been well defined. We evaluated whether ED boarding among ICU-bound adults with DKA is associated with delayed DKA resolution and increased morbidity and mortality.

We performed a retrospective cohort study of adults in DKA who presented to one of 18 EDs who received an insulin infusion and were admitted to a medical ICU between January 1, 2022, and December 31, 2024. Boarding was defined as ED stay ≥3 hours after admission decision. Continuous variables were summarized as mean ±SD or median [IQR] and categorical variables as frequency (%). Groups were compared using t-test or Wilcoxon rank-sum tests and chi-square or Fisher’s exact tests. The primary outcome was time to DKA resolution measured by insulin infusion duration, which was log-transformed for skewness. Multivariable linear regression estimated the ratio of geometric means between groups adjusting for age, sex, race, ethnicity, insurance, acuity, and Charlson Comorbidity Index.

There were 632 patients included in the analysis. ED boarded patients (n=153) were older, had higher acuity and greater comorbidity burden. They required longer insulin infusion duration (17.0 [10.5, 24.2] vs 15.3[6.0, 21.3], p=0.015). After adjustment, boarding was associated with a 27% longer insulin duration (geometric mean ratio 1.27, 95% CI 1.07–1.51, p=0.007). Boarded patients also had longer hospital length of stay (2.1[1.3,3.6] vs 1.8 [1.1, 2.4] days, p<0.001), higher inpatient (12% vs 5%, p=0.005) and 30-day mortality (15% vs 7%,p=0.001), lower DKA pathway use (65% vs 88%, p<0.001), and more acute kidney injury (25% vs 13%,p<0.001). ICU length of stay did not differ between groups.

Among ICU-bound adults with DKA, ED boarding was independently associated with delayed DKA resolution and higher morbidity and mortality. These findings suggest that ED boarding may disrupt time-sensitive DKA care pathways and represent a modifiable systems-level target to improve outcomes in this high-risk population.