Background: Evidence-based guidelines/protocols for electrolyte replacement that safely encourage oral (PO) and/or intravenous (IV) dosing attain goal levels more successfully than standard care. PO is generally more comfortable and less dangerous than IV. Between 5/2017-11/2017, our institution dosed ~300,000 doses of potassium (K) and magnesium (Mg), with 30% and 19% of doses being PO, respectively. If 10% of K/Mg doses were switched to PO, we anticipate >$100,000 in annual hospital savings and improved care.
Purpose: Our objective was to implement an electronic electrolyte guideline for K/Mg repletion to increase oral delivery and improve repletion efficacy.
Description: We created a multidisciplinary team and completed a literature review to update our guidelines. Goals included renal dosage adjustment, administration-route and formulation-choice suggestion based on clinical status, telemetry monitoring and nephrology consult guidance, and clear guideline-use exclusions. We also sought to include appropriate situational awareness and utilized behavioral economic “nudge” theory into the electronic orderset to improve patient care while reducing provider cognitive load. We attained approval for implementation of the new guidelines (Figure 1) in 6/2019 (period “1”).In 2/2020 (“2”) the updated guidelines were uploaded to the institutional intranet. The electronic orderset was released in 10/2020 (“3”). Given limited orderset use, inpatient IV K and Mg orders access was restricted to the orderset in 6/2021 (“4”). The orderset was extended to the emergency department in 10/2021 (“5”).A small (n=30) quality check in 1/2021 found K and Mg were repleted to within normal limits (WNL) in 94% and 100% of patients, respectively, when using the orderset without instances of overcorrection. PO repletion rates were 76% and 63%, respectively.EHR-level order data was used to assess larger trends. Data discrepancies exist between 2017 data (“0”) and recent data (“1”-“5”) so we compared only our main hospital’s data for significance across the “1”-“5” time periods (Figure 2) for 152,818 K/Mg inpatient orders. Relative to period 1 (%PO 51%/23%, K/Mg), the uploading of the guidelines and creation of the electronic orderset had limited to negative effects (stage 2: 49%/20%, stage 3: 50%/19%). Of note, during period 3 the orderset accounted for 4%/4% of all K/Mg orders. This rose to 40%/69%, respectively, in period 4 when %PO repletion rose 8%/78% to 54%/34%, respectively, for K/Mg after restricting IV repletion access to the orderset. These changes were significant (< 0.00001) using a two proportion Z test. Stage 5 saw downtrends to 51%/32%, respectively.
Conclusions: An evidence-based K/Mg repletion guideline and accompanying orderset that restricts access to IV K/Mg orders to an accompanying orderset significantly increases %PO K/Mg repletion. This increase has theoretical benefits on patient/hospital cost, patient comfort, and fewer adverse effects. A small sample suggested the guideline-based repletion attained excellent rates of repletion to WNL without evidence of over correction – these theoretical and small-sample findings will need further confirmation as such findings would confirm ICU-level studies, be one of the first such reports for non-ICU floor patients and pave the way for high-value, safe, patient-centered electrolyte repletion.