From the 2018 HVPAA National Conference
Brian Grundy (Dell Medical School at The University of Texas, Austin), Richard Bottner (Dell Medical School at The University of Texas, Austin), Danish Mirza (Dell Medical School at The University of Texas, Austin), Kirsten Roberts (Dell Seton Medical Center at the University of Texas), Victoria Valencia (Dell Medical School at The University of Texas, Austin), Chris Moriates (Dell Medical School at The University of Texas, Austin), Chris Stearns (Dell Medical School at The University of Texas, Austin)
A nurse-driven intravenous potassium replacement sliding scale order set can enable nurses in an inpatient setting to replace low serum potassium without direct input from physicians but can lead to patient harm, delays in care and increased costs. There is good evidence that PO K administration is safer than IV.
Our objective was to implement a quality improvement project to reduce the number of inappropriate IV potassium administrations by 50% on the acute care inpatient floors of our hospital over a 2-month intervention period.
Our intervention included all patients with the IV potassium replacement sliding scale order set on the acute care floors at Dell Seton Medical Center at the University of Texas at Austin, a 211-bed teaching hospital.
Our intervention included a change in the EMR order protocol for the IV K sliding scale, data feedback from patient chart review, and physician and nursing education.
The change to the EMR order set allowed pharmacists to review orders on a daily basis and discontinue or convert the IV potassium sliding scale to PO when the patient met criteria for doing so, including a non-NPO status and or a status of NPO except for medications. Nurses could call the pharmacist to reorder the IV sliding scale if a patient was unable to tolerate PO.
At the initiation of this intervention, nurses and physicians were encouraged to reduce IV K sliding scale use and use PO when able, and taught how to appropriately replace potassium. During the intervention charts were reviewed for episodes of IV potassium administrations using the sliding scale and feedback was given to nurses and physicians through email or personal communication when IV K use was deemed inappropriate.
Over a 60-day period prior to our intervention, there were 255 (approx. 27/week) administrations of IV potassium given to 82 patients using the IV potassium sliding scale order. Of these 255 IV administrations, it was determined 212 (83%) were inappropriately given based on our criteria.
Once our intervention began, the total number of IV K sliding scale administrations over the following 60 days was 122 (approx. 15/week). Chart review indicated 40 of these administrations (33%) were inappropriate. There were no observed adverse outcomes from reducing IV potassium use.
Our multimodal and multi-disciplinary quality improvement project of nursing and physician education and pharmacist engagement resulted in an overall reduction in IV potassium use by 52% and inappropriate use by 60%.
By involving not only the prescribers but also those who approve and administer the medications, we were able to make a quick and effective improvement in the care of our patients. We continue to monitor IV potassium administrations and find ways to improve upon our intervention to further reduce inappropriate use.
We hope to expand our intervention to our 11-hospital network and determine further ways to improve appropriate potassium replacement and evaluate the sustainability of our intervention.
Implications for the Patient
IV potassium use is uncomfortable for patients, and may result in complications including thrombophlebitis and hyperkalemia. IV potassium costs more than PO and requires more nursing time.
A multi-disciplinary, multimodal approach can result in a large institutional change in culture and practice, resulting in improved patient care, comfort, and safety.