Baltimore—A new software-based protocol for standardizing electrolyte replacement therapy (ERT) across multiple sites and types of care has yielded major improvements in speed and accuracy, according to a task force of health professionals at Sentara Obici Hospital, in Suffolk, Va.

With the new system in place, nine of every 10 patients who are candidates for ERT now get the infusions in a timely manner, with the ingredients well matched to the metabolic needs of the patients—a rarity before the system was implemented, the team reported in a poster presented at the 2012 Summer Meeting of the American Society of Health-System Pharmacists.

The protocol was designed and developed in-house by a cross-disciplinary team of physicians, nurses, pharmacists and information technology professionals, according to task force member Olubukola Fakunle-Adeyemi, PharmD. Introduced a little over a year ago, the new system was implemented throughout the hospital, in contrast to the previous system, which at one point included three different ERT protocols, depending on the level of care under which patients were placed: critical care, step-down electrolyte replacement or medical/surgical. Each level of care addressed different electrolyte deficiencies and gave different replacement options—a setup that was not working for patients or caregivers, Dr. Fakunle-Adeyemi noted. The issue came to a head in 2010 when an audit under the old system found that, of 14 patients in need of ERT, none received the correct potassium replacement and no follow-up labs were ordered.

The main electrolytes in body fluid: Na+, sodium ion; Cl–, chloride ion; Mg2+, magnesium ion; Ca2+, calcium ion; K+, potassium ion.

“The existing protocols were complex and we saw an opportunity for improvement,” said Lee Knill, RN, one of the primary authors of the new protocol. “Of all the possible ERT choices listed on the medication administration record, nursing staff had no way of knowing which choice to select for a particular lab reading,” Ms. Knill explained. They also were required to get authorization from the attending physician each time electrolyte levels fell within a critical level range. “They would have to remember to order follow-up labs,” she added, pointing to the system’s lack of automatic prompts for further action, a shortcoming exacerbated during shift change.

In March 2011, the new, single protocol was piloted to enhance the hospital’s electronic medical administration record (eMAR) system, which it maintains for each patient. The initiative was developed to address the lack of nurses’ autonomy in selecting the appropriate ERT, and also to address the overarching problem of physicians, pharmacists and nurses not being able to communicate effectively.

The new protocol streamlines the process for administering ERT regardless of a patient’s level of care. It allows physicians to create “implement” orders for the entire ERT protocol or for each individual electrolyte, and it specifically lists the critical value replacement parameters (Figure). In a departure from the old system, ERT requirements are now entered on the eMAR as “scheduled” medications instead of “PRN” or “as needed,” giving nursing staff and pharmacists clear instructions on the levels and timing of doses, the criteria for administering and repeating them and when to order follow-up labs.

Figure. Electronic protocol tool for enhancing compliance with electrolyte therapy.

One month after implementation, a follow-up audit of 18 patients showed that there still was some room for improvement: of 30 scenarios requiring potassium replacement, 22 followed protocol (73.3%) but only five (17%) had labs drawn correctly. As a result, the development team added several enhancements, such as changing follow-up labs to daily instead of four hours after the last dose (except for lab draws associated with critical values). The most recent audit (April-May 2012) showed that those efforts have paid off: of 51 opportunities for ERT, 48 followed protocol (94%). Of 48 opportunities for lab follow-ups, 47 (98%) were drawn correctly.

Overall compliance with the protocol continues to exceed 90%—a result that, “although very encouraging, perhaps was to be expected, because this new system is so much easier for both the physician to order and the bedside nurse to use,” Dr. Fakunle-Adeyemi said.

image Physicians still must be alerted if a patient shows critical-value electrolyte levels, she added, but nurses now have the autonomy to act within the parameters set out by the new system. However, it is not mandatory for a physician to order the protocol for each and every patient. “That’s the only way a protocol will work,” Dr. Fakunle-Adeyemi said. “You have to stay on it and hammer it home through education, education, and even more education.”

Kudos for the New Initiative

ERT protocols standardize the way electrolytes are ordered and administered—something that most physicians do randomly, according to Todd Canada, PharmD, BCNSP, a nutrition specialist at the University of Texas MD Anderson Cancer Center, in Houston. Such a lack of standardization can negatively affect patient safety, Dr. Canada said. He cited, as an example, studies showing that heart surgery patients on diuretics who did not receive appropriate potassium-containing ERT had an elevated risk for cardiac arrhythmias (JAMA 1999;281:2203-2210; J Am Coll Cardiol 2004;44:938-939).

“Most clinicians have received little other than ‘on-the-job’ training during their residencies about how important it is to replace an electrolyte abnormality, [or] the urgency and the appropriate way to order it for patient safety,” he said. “So programs such as the one in place at Sentara Obici are sorely needed.”

Dr. Canada stressed, however, that hospitals should be ready for a potential increase in workload if they succeed in revamping their ERT protocols and boost compliance with ERT. “Remember, 5% to 15% of hospitalized patients have at least one electrolyte abnormality upon admission, and this number is even higher in critically ill patients,” he said. “So it is quite possible that by improving your system for identifying viable candidates for ERT, you soon will be replacing electrolytes in patients who previously were missed by your clinical staff. That means increased workload for your pharmacists and nurses.”

Dr. Canada added that boosting compliance with ERT also may exacerbate electrolyte shortages, “which will require prioritizing the most appropriate patients to receive the available supply.”

Are those challenges reason to shy away from ERT process improvement? “Absolutely not,” Dr. Canada said. “Rather, do it with eyes wide open, and realize that you may have to draw on more staff resources to pull it off.”

—Maureen Sullivan