Implementation and evaluation of a nurse-centered computerized potassium regulation protocol in the intensive care unit--a before and after analysis

Miriam Hoekstra, Mathijs Vogelzang, José T Drost, Marcel Janse, Bert G Loef, Iwan C C van der Horst, Felix Zijlstra, Maarten W N Nijsten, Miriam Hoekstra, Mathijs Vogelzang, José T Drost, Marcel Janse, Bert G Loef, Iwan C C van der Horst, Felix Zijlstra, Maarten W N Nijsten

Abstract

Background: Potassium disorders can cause major complications and must be avoided in critically ill patients. Regulation of potassium in the intensive care unit (ICU) requires potassium administration with frequent blood potassium measurements and subsequent adjustments of the amount of potassium administrated. The use of a potassium replacement protocol can improve potassium regulation. For safety and efficiency, computerized protocols appear to be superior over paper protocols. The aim of this study was to evaluate if a computerized potassium regulation protocol in the ICU improved potassium regulation.

Methods: In our surgical ICU (12 beds) and cardiothoracic ICU (14 beds) at a tertiary academic center, we implemented a nurse-centered computerized potassium protocol integrated with the pre-existent glucose control program called GRIP (Glucose Regulation in Intensive Care patients). Before implementation of the computerized protocol, potassium replacement was physician-driven. Potassium was delivered continuously either by central venous catheter or by gastric, duodenal or jejunal tube. After every potassium measurement, nurses received a recommendation for the potassium administration rate and the time to the next measurement. In this before-after study we evaluated potassium regulation with GRIP. The attitude of the nursing staff towards potassium regulation with computer support was measured with questionnaires.

Results: The patient cohort consisted of 775 patients before and 1435 after the implementation of computerized potassium control. The number of patients with hypokalemia (<3.5 mmol/L) and hyperkalemia (>5.0 mmol/L) were recorded, as well as the time course of potassium levels after ICU admission. The incidence of hypokalemia and hyperkalemia was calculated. Median potassium-levels were similar in both study periods, but the level of potassium control improved: the incidence of hypokalemia decreased from 2.4% to 1.7% (P < 0.001) and hyperkalemia from 7.4% to 4.8% (P < 0.001). Nurses indicated that they considered computerized potassium control an improvement over previous practice.

Conclusions: Computerized potassium control, integrated with the nurse-centered GRIP program for glucose regulation, is effective and reduces the prevalence of hypo- and hyperkalemia in the ICU compared with physician-driven potassium regulation.

Figures

Figure 1
Figure 1
Nurse-centered potassium regulation cycle with GRIP-II. Nurse-driven potassium regulation with GRIP-II. After taking a blood sample and analyzing it with the point of care machine, the GRIP-II system automatically retrieves the new potassium value from the hospital information system. GRIP-II then advises about the potassium pump rate, and the time to the next blood sample. This total cycle, including also the glucose measurement and insulin pump rate advice takes 4 minutes and is performed 6 times a day.
Figure 2
Figure 2
Diagram of the GRIP-II potassium algorithm. A schematic diagram of the potassium infusion recommendation algorithm of GRIP-II. Note that the exact source code to the algorithm is freely downloadable from the project web site http://grip-glucose.sf.net/.
Figure 3
Figure 3
Time course of potassium. Time course of medians with 25- and 75-percentiles (i.e. interquartile ranges, indicated by error bars) and 5- and 95-percentiles of potassium during the first ICU day. The grey lines reflect the situation before and the black lines reflect the situation after GRIP-II. With preservation of the same median potassium levels, GRIP-II achieved a lower number of potassium levels that were out of range (P < 0.001).

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Source: PubMed

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