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Potassium Replacement Protocol

St. Anthony Hospital Protocol

Presented by: Kayla, Korri, Karan, Leyna

K+ Protocol >/= 3.5

Don't initiate if Creatinine >2mg/dL, Patient weight <45kg, Patient on dialysis or CRRT - OR - UOP <20ml/hr, 175ml per 8hr shift or 250ml per 12hr shift 

Reminder: Verify lab value from earlier in day was not replaced earlier

On initiation of protocol, if no K+ in last 24hours, draw/order K+ level. On initiation and prior to any subsequent doses, if no creatinine in the last 48 hours, order using order set. 

If K+ less than 3, order Magnesium levels

PO dosing is preferred. Give IV dosing only if has nausea, vomiting, diarrhea, NG to suction or NPO.

PROTOCOL

K< or =2.4

KCl 10 mEq IV Q1H x 10 doses via peripheral/central line and call MD.

KCl 20 mEq IV Q1H x 5 doses - Only in ICU. Administrate via central line only and call MD. 

**Recheck level: 1 hour after last dose

Check Mg level if not already done.

K 2.5-2.9

KCl 40 mEq liquid (PO/NG) Q2H x 2 doses - OR - KCl 10 mEq IV Q1H x 8 doses via peripheral or central line.

KCl 20 mEq IV Q1H x 4 doses - Only in ICU. Administrate via central line only.

**Recheck level: 2 hours after last PO/NG dose 

1 hour after last IV dose. Check Mg. 

K 3-3.4

KCl 20 mEq liquid Q2H x 3 doses (PO/NG) - OR - 2 x 10 mEq capsules PO Q2H x 3 doses 

- OR - KCl 10 mEq IV Q1H x 6 doses via peripheral/central line 

KCl 20 mEq IV Q1H x 3 doses - Only in ICU.  Administrate via central line only.

**Recheck level: ICU/Tele - 2 hours after last PO/NG or 1 hour after last IV dose 

Med/Surg - 4 hours after last dose or with next lab if within 12 hours.

Application to Clinical Setting

Protocol Based Care

  • Compare and Contrast
  • Evidence tested IV infusions only
  • Protocol in hospital allows PO form of replacement therapy within a specific range
  • Implementation via HIT
  • Changes/Limitations
  • Computerized: have paper versions available for computer complications
  • Encourage interdisciplinary participation and communication with abnormal lab values
  • Educate on protocols to prevent missed episodes

  • Goal: Helps healthcare providers to put evidenced based research into practice in order to reduce morbidity and mortality through early and efficient intervention, implements national standards in care

  • Standardization – reduce variations in care and outcomes
  • Extends roles – nurses, interdisciplinary care and participation
  • Improve Patient experience and shorter hospital stays
  • “What should be done, when, and by whom”
  • Used:
  • Conditions/diseases that are relatively predictable
  • Large number of people acquire condition/disease
  • Procedure would be high cost
  • High risk area to hospital

Importance to Nursing Practice

Evidence and Studies

-The different protocols in place decrease the rate of mortality and morbidity rates

- Improves nurse satisfaction

-empowers nurses

-Decreases the risk for hypokalemia and hyperkalemia and the complications that are associated with them

-Hypokalemia: Weakness, fatigue, muscle cramps, pain, worsening diabetes

control, polyuria, palpitations, and other cardiac complications

-Hyperkalemia: Mostly Cardiac complications that can lead to renal

complications.

Implementation and evaluation of a nurse-centered computerized potassium regulation protocol in the intensive care unit - a before and after analysis. 

Preventing Hypokalemia in Critially Ill Patients

Evaluation of An Electrolyte Replacement Protocol for Cardiac Surger Intensive Care Patients

Objective: evaluate effectiveness and safety of electrolyte replacement protocol (Potassium) in large group of postop patients (coronary artery bypass)

Design: Retrospective Study, Level 4

  • Sample: Patients 18yrs and older admitted to ICU following coronary artery bypass surgery,
  • Exclusions - renal replacement therapy, diabetic ketoacidosis, wt < 45kg, patients who died during and post surgery
  • 627 included in the study: 312 control and 315 in protocol group
  • Randomized computer generator to select patients for study
  • 2 year study period
  • Medical Staff remained unchanged
  • Protocol: pre-printed order sheet with predetermined IV replacement doses according to electrolyte levels,
  • Standard electrolyte monitoring (blood draws in the AM following replacement)
  • Desired K range: 3.6-5.0mmol/L

Results: post 2 study periods of 325 patients each period

  • Protocol group: 100% of Serum K within desired range
  • No significant difference between protocol group and control group serum K morning values
  • Multivariate analysis - optimal maintenence of serum potassium concentration within the desired range with replacement and monitoring of lab values post replacement

K+ Protocol of ICU study

  • IV infusion for GFR <30ml/hr or UOP <30ml/hr : 3.6-4.3 Otherwise : 3.8-4.5
  • Range – Lower: IV Infusion
  • In range: Calculate predicted K+ clearance using GFR, diuresis, and presence of hemofiltration
  • Higher: Give no potassium

Research Design

  • Theoretical framework/ Conceptual basis for research: Process Improvement
  • Design: Well-designed controlled trials without randomization
  • Sample (size, target population, setting): 775 patients before and 1435 after the implementation of computerized
  • potassium control over a period of 14917 patient-ICU days , 1300 bed tertiary university teaching hospital: a 12-bed surgical ICU and a 14-bed thoracic-surgical ICU
  • Instrument used: Health Information Technology
  • Level of evidence: Level III, no randomization

  • Process Improvement
  • Well-designed controlled trials without randomization
  • 775 patients before and 1435 after the implementation of computerized potassium control over a period of 14917 patient-ICU days , 1300 bed tertiary university teaching hospital: a 12-bed surgical ICU and a 14-bed thoracic-surgical ICU
  • Health Information Technology
  • Level III, no randomization

What the Evidence Shows

Protocol Driven vs. Physician-driven electrolyte replacement in adult critically ill patients

- Objective: To determine if administering potassium preemptively in maintenance IV fluid would prevent episodes of hypokalemia and reduce the need to potassium boluses

- Design: 267 patient’s medical records reviewed and 156 patients chosen

- Purpose

- Limitations

- Sample size: 156 total patients in study. 76 received potassium maintenance; 80 were control

- Level III evidence

- Further research: Further studies with a prospective design and random assignment to allow for the generalizability of the results are needed. Such studies may indicate a need to update protocols to include provisions for preemptive administration for patients with high maintenance intravenous rates.

- Obstacles?

- Protocol used vs. St. Anthony’s Protocol

- Results of study and application to practice setting: Compared with the control group, patients who were treated empirically with a potassium supplement added to maintenance intravenous fluid at a rate of 72 to 144 mmol/d received significantly fewer potassium boluses throughout their ICU stay

  • Electrolyte replacement protocol: efficient, safe, effective
  • Efficient: less missed episodes, quicker time for implementation of intervention
  • Safe: no complications arose with use of protocol
  • Effective: K levels returned to normal range with replacement
  • Increases Nurse Satisfaction – empowerment
  • Increase Patient Satisfaction – less complications, decreased hospital stays, better patient outcomes

Results

  • Results: Computerized potassium control, integrated with a nurse-centered program for glucose regulation (GRIP) is safe, effective and reduces the prevalence of hypo- and hyperkalemia in the ICU

  • Suggestions for further research:
  • Relations between potassium and outcome can only be investigated when an adequate protocol and infrastructure for realizing potassium control are in place
  • Several variables that influence the potassium regulation are not considered in this potassium regulation protocol
  • Effect of acid-base disorders, insulin infusion and potassium administration route are possible extensions of K+ protocol

Results

  • 2 month test
  • First Month: Physician-Driven and Second Month: Protocol-Driven
  • 43 patients the first month
  • 44 patients the second month
  • No significant difference in episodes of hypokalemia between two groups
  • Time between two groups: P<0.0001 - significant
  • reduction in mean time interval between recognizing low electrolyte values and implementing intervention
  • Physician-Driven: 161 Minutes
  • Protocol-Driven: 19 Minutes
  • Missed Replacements
  • Physician-Driven: 15 episodes
  • Protocol-Driven: 6 episodes
  • K Replacement Dose
  • Physician-Driven: 31.6mmol
  • Protocol-Driven: 24.5mmol

  • Protocol is safe, efficient, and effective - decreasing mortality and morbidity rates
  • Involves Interdisciplinary care improving patient care
  • Increased nurse satisfaction
  • Limitations/Improvement
  • adjustment of potassium protocol to match or exceed physician dose to decrease occurence of post-replacement hypokalemia
  • education to decrease missed episodes
  • encourage interdisciplinary communication of abnormal lab values

Objective: Compare efficiency of protocol-driven electrolyte replacement with physician-driven orders for the correction of hypokalemia, hypomagnesemia, hypophosphatemia

Design: Retrospective, Level 5

  • Conducted before and after implementation of protocol
  • Sample: 600 Bed ICU, all patients >14 admitted to ICU were included in study, 2 groups (physician-driven and protocol driven)
  • Exclusions: serum creatinine > 115, low urine output, dysrhythmias, diabetic ketoacidosis, seizures, weight <45kg, hypocalcemia
  • Data Collection: demographics, daily electrolyte values (Mg, K, PO), time of results, time interval from identifying low values to implementing intervention, replacement doses, post replacement levels, dx
  • ICU Protocol Physician-Driven:
  • nurses chart lab values in flow sheet and communicate low values to physicians - physician order replacement
  • Protocol-Driven:
  • Nurses start replacement using preset dosing without communicating with ICU physicians for order

References

Couture, J., Létourneau, A., Dubuc, A., & Williamson, D. (2013). Evaluation of an Electrolyte Repletion Protocol for Cardiac Surgery Intensive Care Patients. CJHP The Canadian Journal of Hospital Pharmacy. 66(2), 96-103. doi: 2013 Mar-Apr. Retrieved November 11, 2015, from Evaluation of an Electrolyte Repletion Protocol for Cardiac Surgery Intensive Care Patients

Hijazi, M., & Al-Ansari, M. (2005). Protocol-driven vs. physician-driven electrolyte replacement in adult critically ill patients. Annals of Saudi Medicine, 25(2), 105-109. doi:2005 Mar-Apr

Hoekstra, M., Vogelzang, M., Drost, J., Janse, M., Loef, B., van der Horst, I., & ... Nijsten, M. (2010). Implementation and evaluation of a nurse-centered computerized potassium regulation protocol in the intensive care unit - a before and after analysis. BMC Medical Informatics & Decision Making, 10(1), 5-5 1p. doi:10.1186/1472-6947-10-5

Protocol Based Care. (2013). Retrieved November 11, 2015, from http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/protocol_based_care.html

Scotto, C. J., Fridline, M., Menhart, C. J., & Klions, H. A. (2014). PREVENTING HYPOKALEMIA IN CRITICALLY ILL PATIENTS. American Journal Of Critical Care, 23(2), 145-149 5p. doi:10.4037/ajcc2014946

ECG

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