At least at our academic medical center, we find it very hard to get a DKA patient admitted to an ICU or IMC while they are still in DKA. Typically, we can correct the acidosis and downgrade them to a floor bed before their ICU/IMC bed is available.
Some key points to remember when managing DKA in the ED.
The mainstay of treatment for the hyperglycemia initially is IV fluids.
Check labs often and replete Magnesium and Potassium early.
Insulin should not be started until the potassium is confirmed to be >3.3 mEq/L
Patients can still be in DKA even though there glucose is normal.
Intravenous insulin must be continued until all the ketones are cleared.
Add D5W or D10 if needed to ensure that their glucose levels stay up but do not stop the insulin.
Patients need to receive a long acting insulin (i.e.: Lantus or NPH) 2 hours before the insulin drip is stopped. Placing a patient only on Sliding Scale Insulin will almost guarantee that they go back into DKA on the floor.
Typically you can just restart the patients home long acting insulin, but if you are leary about hypoglycemia if they are not eating well, then give them 3/4 their home dose.
References
Charfen MA, Fernadez-Frackelton M. Diabetic Ketoacidosis. EMCNA 2005:609-628.
