Background: The electrolyte order set (“hub”) at our institution encourages electrolyte repletion based on evidence-based guidelines for patients at risk of arrhythmias, their renal function, and preference of oral over IV repletion. The hub has successfully improved repletion efficacy and route. Replacement, however, often starts at night, leading to potential sleep disturbance. The latest hub iteration thus defaulted administration time to the next morning when ordered overnight unless the patient’s electrolytes conferred and elevated arrhythmia risk per AHA guidelines. Clinicians retained the ability to order “off-guideline” to access any repletion type, route, or timing, and these off-guideline orders did not include the default adjustment to morning administration. It went live in May 2025.
Methods: Overnight was defined as 10 PM to 6 AM. A clinically significant change in overnight administrations was pre-defined as a relative reduction of 10% from a seasonally adjusted baseline, 6/1/24-10/31/24 (“Pre”) relative to the period after the latest hub was launched (6/1/25-10/31/25, “Post”). Data was extracted from Qlik. Orders and administration data for all potassium and magnesium were matched and analyzed in Excel. Chi-squared analysis was used with significance defined as p< 0.05. 95% Confidence Intervals (“CI”) were added for context.
Results: In Pre, 141,808 electrolytes were administered across 11 hospitals; 17.01% occurred overnight. In Post, 195,555 electrolyte products were administered; 15.12% occurred overnight. All results were significant. The relative reduction in overnight administrations was 11.07% (95% CI: 9.59%-12.55%). When electrolytes were ordered per guidelines, overnight administrations dropped from 18.82% to 15.42% (18.06% relative reduction, 95% CI: 16.35%-19.73%). When clinicians chose off-guideline, there was a relative increase in overnight administrations of 6.88% (95% CI: 3.75%-10%).
Conclusions: The data confirms that adjusted default timing of electrolyte administration significantly reduces overnight administration. The relative reduction met our pre-defined goal though we do note that the lower end of the CI just falls short (9.6%). Extrapolating, this intervention leads to 8,917 fewer overnight electrolyte administration patient disruptions per year. Given more dramatic overnight reduction when clinicians ordered on-guideline, if we can encourage on-guideline adherence, we can drive reduction of overnight disruptions due to electrolytes to nearly 16,000 fewer disruptions per year. Prior study has suggested this hub dramatically improves route, efficacy, and cost of repletion; we now know its latest iteration also significantly reduces overnight disturbances. Such reductions are known to reduce delirium and improve patient satisfaction, so we will need to explore whether the hub improvements are also associated with these secondary improvements.