Reducing Routine Ionized Calcium Measurement

Baird, Geoffrey S.; Rainey, Petrie M.; Wener, Mark H.; Chandler, Wayne L.

doi:10.1373/clinchem.2008.116707

Cited by 33 publications

(22 citation statements)

References 16 publications

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“…Our results suggest that calcium supplementation does not lead to a greater sustained increase in ionized calcium than occurs without supplementation. This is in keeping with previous reports suggesting that calcium supplementation does not increase ionized calcium concentrations in critical illness and that calcium concentrations cannot be corrected by calcium therapy alone [20,29,30]. However, it needs to be taken into consideration that our study was retrospective and observational and hence lacks controlled intervention.…”

Section: Discussionsupporting

confidence: 89%

Assessment and clinical course of hypocalcemia in critical illness

et al. 2013

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IntroductionHypocalcemia is common in critically ill patients. However, its clinical course during the early days of admission and the role of calcium supplementation remain uncertain, and the assessment of calcium status is inconsistent. We aimed to establish the course of hypocalcemia during the early days of critical illness in relation to mortality and to assess the impact of calcium supplementation on calcium normalization and mortality.MethodsData were collected on 1,038 admissions to the critical care units of a tertiary care hospital. One gram of calcium gluconate was administered intravenously once daily to patients with adjusted calcium (AdjCa) <2.2 mmol/L. Demographic and outcome data were compared in normocalcemic (ionized calcium, iCa, 1.1-1.3 mmol/L) and mildly and severely hypocalcemic patients (iCa 0.9-1.1 mmol/L and <0.9 mmol/L, respectively). The change in iCa concentrations was monitored during the first four days of admission and comparisons between groups were made using Repeated Measures ANOVA. Comparisons of normalization and outcome were made between hypocalcemic patients who did and did not receive calcium replacement according to the local protocol. The suitability of AdjCa to predict low iCa was determined by analyzing sensitivity, specificity and receiver operating characteristic (ROC) curves. Multivariate logistic regression was performed to determine associations of other electrolyte derangements with hypocalcemia.Results55.2% of patients were hypocalcemic on admission; 6.2% severely so. Severely hypocalcemic patients required critical care for longer (P = 0.001) compared to normocalcemic or mildly hypocalcemic patients, but there was no difference in mortality between groups (P = 0.48). iCa levels normalized within four days in most, with no difference in normalization between those who died and survived (P = 0.35). Severely hypocalcemic patients who failed to normalize their iCa by day 4 had double the mortality (38% vs. 19%, P = 0.15). Neither iCa normalization nor survival were superior in hypocalcemic patients receiving supplementation on admission. AdjCa <2.2 mmol/L had a sensitivity of 78.2% and specificity of 63.3% for predicting iCa <1.1 mmol/L. Low magnesium, sodium and albumin were independently associated with hypocalcemia on admission.ConclusionsHypocalcemia usually normalizes within the first four days after admission to ICU and failure to normalize in severely hypocalcemic patients may be associated with increased mortality. Calcium replacement appears not to improve normalization or mortality. AdjCa is not a good surrogate of iCa in an ICU setting.

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Section: Discussionsupporting

confidence: 89%

Assessment and clinical course of hypocalcemia in critical illness

et al. 2013

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“…One academic medical center decreased iCa orders by approximately 75% by establishing a reflex calcium test, such that iCa was performed only when total serum calcium was Ͻ8.0 mg/dL or Ͼ10.2 mg/dL. Direct (without the total calcium reflex) iCa orders were still allowed, but only by special request (18 ). We chose not to pursue this strategy, primarily because iCa is ordered approximately 3 times more often than total calcium in our ICU practice.…”

Section: Discussionmentioning

confidence: 99%

Implementation of Clinical Decision Support Rules to Reduce Repeat Measurement of Serum Ionized Calcium, Serum Magnesium, and N-Terminal Pro-B-Type Natriuretic Peptide in Intensive Care Unit Inpatients

et al. 2016

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“…In a pair of large academic medical centres, for example, daily ionized calcium testing had become ingrained into the culture of the house staff and was ordered in nearly every patient. When daily ionized calcium testing was reduced by approximately 70% by introducing a reflexive testing strategy, doses of calcium administered by the pharmacy in the hospitals decreased by a very similar fraction, as did the diagnoses of “hypocalcemia” rendered by the providers (32). While not enumerated in the report, it is likely that the cost savings of these downstream effects far outstripped the laboratory-specific savings.…”

Section: The Three Rules Of Laboratory Test Utilizationmentioning

confidence: 99%

The laboratory test utilization management toolbox

Baird

2014

Biochem Med

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Efficiently managing laboratory test utilization requires both ensuring adequate utilization of needed tests in some patients and discouraging superfluous tests in other patients. After the difficult clinical decision is made to define the patients that do and do not need a test, a wealth of interventions are available to the clinician and laboratorian to help guide appropriate utilization. These interventions are collectively referred to here as the utilization management toolbox. Experience has shown that some tools in the toolbox are weak and other are strong, and that tools are most effective when many are used simultaneously. While the outcomes of utilization management studies are not always as concrete as may be desired, what data is available in the literature indicate that strong utilization management interventions are safe and effective measures to improve patient health and reduce waste in an era of increasing financial pressure.

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Reducing Routine Ionized Calcium Measurement

Abstract: BACKGROUND:Ionized calcium (iCa) is measured frequently in hospitalized patients, and hypocalcemia is frequently found, seemingly supporting the practice.

Cited by 33 publications

References 16 publications

Assessment and clinical course of hypocalcemia in critical illness

Assessment and clinical course of hypocalcemia in critical illness

Implementation of Clinical Decision Support Rules to Reduce Repeat Measurement of Serum Ionized Calcium, Serum Magnesium, and N-Terminal Pro-B-Type Natriuretic Peptide in Intensive Care Unit Inpatients

The laboratory test utilization management toolbox

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