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

Abstract

BACKGROUNDThe intensive care unit is a dynamic environment, where high numbers of patients cared for by health care workers of different experiences and backgrounds might result in great variability in patient care. Protocol-driven interventions may facilitate timely and uniform care of common problems, like electrolyte disturbances. We prospectively compared protocol-driven (PRD) vs. physician-driven (PHD) electrolyte replacement in adult critically ill patients.PATIENTS AND METHODSIn the first month of the two-month study, potassium, magnesium, and phosphate levels were checked by a physician before ordering replacement (PHD replacement period). Over the second month, ICU nurses proceeded with replacement according to the protocol (PRD replacement period). We collected demographic data, admission diagnosis, number of potassium, magnesium, and phosphate levels done per day, number of low levels per day, number of replacements per day, time between availability of results to ordering replacement, time to starting replacement, post-replacement levels, serum creatinine, replacement dose, arrhythmias and replacement route.RESULTSDuring the PHD replacement period, 43 patients meeting the inclusion criteria were admitted to the ICU, while 44 were admitted during the PRD month. The mean time (minutes) from identifying results to replacement of potassium, phosphate and magnesium was significantly longer with PHD replacement compared with PRD replacement (161, 187, and 189 minutes vs. 19, 26, and 19 minutes) (P<0.0001). The number of replacements needed and not given was also significantly lower in the PRD replacement period compared with the PHD replacement period (2, 4, and 0 compared with 9, 6 and 0) (P<0.05). No patients had high post-replacement serum concentrations of potassium, phosphate or magnesium.CONCLUSIONSThis study shows that a protocol-driven replacement strategy for potassium, magnesium and phosphate is more efficient and as safe as a physician-driven replacement strategy.

Low-mortality death in hospitals after vertical integration with Health Maintenance Organizations

“…Literature supports the effectiveness of protocol on positive patient outcomes on a wide range of different workflow processes and procedures. [17][18][19][20] Standardized protocols decrease unwarranted variability, which could result in lower low-mortality death rates following a merge with an HMO, consistent with our findings. [18] Further, it is possible that merging with an HMO allows a hospital access to a wider array of resources and more specialized care for their patients.…”

Evaluation of an Electrolyte Repletion Protocol for Cardiac Surgery Intensive Care Patients

“…1 The effectiveness and safety of protocols to optimize electrolyte management and facilitate the care of critically ill patients have been demonstrated in only a limited number of studies. [17][18][19][20] The protocol used in the current study hospital was similar to those previously published, but suggested replacement doses of electrolytes were generally higher, and calcium repletion was included. The results of this study showed that this electrolyte repletion protocol was safe and led to better control of daily serum potassium concentration.…”

“…[13][14][15][16] To date, 4 studies have evaluated repletion protocols for multiple electrolytes in various intensive care settings. [17][18][19][20] The results of these studies have suggested that use of repletion protocols is more effective than standard approaches to electrolyte repletion. [18][19][20] However, these studies have been limited by small sample sizes and important between-group differences in clinical characteristics that may have biased the results.…”

Preventing Hypokalemia in Critically Ill Patients

“…6 Current practice favors using protocols for potassium bolus replacement to treat hypokalemia when the abnormality occurs. 15 Evidence 16,17 indicates that implementation of computer-or nurse-prompted replacement protocols can decrease the time between the measuring of serum potassium levels and subsequent administration of a potassium bolus. Although use of these protocols improves the efficiency of potassium delivery, they still leave patients vulnerable to the effects of hypokalemia.…”

“…This dose is similar to that recommended in other protocols. 16,17 After the study was approved by the appropriate institutional review board, a list of patients admitted to critical care who had received intravenous potassium boluses or had potassium added to the intravenous maintenance fluid was generated from pharmacy records for the period January 2008 through July 2011. Medical records were reviewed, and patients were included in the study if they had received intravenous maintenance fluid at 75 to 150 mL/h for at least 48 hours, had a serum creatinine level of 1.4 mg/dL or less (to convert to micromoles per liter, multiply by 88.4), had a serum potassium level of 3.5 to 5.5 mmol/L, and did not receive total parenteral nutrition.…”