Evaluation of an Emergency Department‐based Advanced Care Unit for diabetic ketoacidosis management in a resource‐limited community hospital setting

Abstract Introduction North Lantau Hospital, a geographically isolated community hospital without an intensive care unit (ICU), faces unique challenges in managing critically ill patients, including those with diabetic ketoacidosis (DKA). This study evaluates the impact of an innovative Emergency Department‐based Advanced Care Unit (EMACU) staffed by Emergency Department Intensivists (EDIs) on ICU admission rates and outcomes for DKA patients. Methods This retrospective pre‐post cohort study compared adult DKA patients eligible for EMACU‐level care before (January 2014–October 2020) and after (January 2022–September 2025) EMACU implementation. The primary outcome was the ICU admission rate. Secondary outcomes included time to metabolic resolution, length of stay (LOS), and in‐hospital mortality. Results After exclusions, 64 pre‐EMACU and 45 post‐EMACU eligible DKA patients were analyzed. EMACU implementation significantly reduced ICU admissions from 43.8% (28/64) to 13.3% (6/45) (absolute risk reduction 30.5%, p < 0.001). Patients managed in EMACU ( n = 33) were comparable to those previously admitted to ICU ( n = 28) in DKA severity. In‐hospital mortality was low and similar (3.6% vs. 3.0%, p = 0.906). While EMACU LOS was longer (4.3 vs. 2.7 days, p = 0.017), this was influenced by confounders including a high proportion of tourists with truncated stays in the ICU cohort and infection‐complicated DKA in the EMACU cohort. Conclusion The EMACU with EDI model provides a safe and effective approach to managing selected DKA patients in a resource‐limited community hospital, significantly reducing ICU admissions while preserving ICU capacity for patients with critical care needs.