Hypokalaemia in hospitalised patients
QUESTIONS UNDER STUDY: Hypokalaemia in inpatients is common, and is associated with morbidity and mortality. Its management is risky and not always effective. We launched an educational programme with the aim of increasing the rate of potassium normalisation during hospital stay, and of reducing unmonitored cases.
METHODS: The project consisted of three phases: (I) retrospective analysis on 26 471 patients hospitalised in 2012 in five acute care hospitals of southern Switzerland (Ente Ospedaliero Cantonale, EOC) with identification of improvement goals on a sample survey (588 cases of hypokalaemia); (II) revision of internal guidelines, and implementation of educational activities in one of the five hospitals (Ospedale Regionale di Locarno, ODL); (III) follow-up analysis on the 26 726 patients hospitalised in 2014 and second sampling to complete the evaluation of the efficacy of the intervention.
RESULTS: Phase I, ODL vs EOC: prevalence of hypokalaemia, 21.7 vs 23.2% (p <0.05); treated 53.1 vs 56.5% (not significant); normalisation 62.4 vs 61.1% (ns); absence of monitoring 18.3 vs 21.1% (p <0.05); time to normalisation 3.0 ± 2.7 vs 2.8 ± 2.4 days (ns); secondary hyperkalaemia 1.1 vs 1.4% (ns). Length of stay hypokalaemic vs normokalaemic 11.2 ± 11.7 vs 6.6 ± 7.9 days (p <0.001); falls 3.5 vs 1.7% (p <0.001), deaths 5.1 vs 3.1% (p <0.001). The severity/performance ratio suggested inefficiency. Phase III, ODL 2012 vs ODL 2014: treated 53.1 vs 75.7% (p <0.001); normalisation 62.4 vs 69.7% (p <0.01); absence of monitoring 20.1 vs 8.7 (p <0.01); time to normalisation 3.1 ± 2.7 vs 2.4 ± 2.6 days (ns); secondary hyperkalaemia 1.1 vs 1.8% (ns).
CONCLUSIONS: The management of hypokalaemia is characterised by dysfunctions; it can, however, be ameliorated by the implementation of internal guidelines and targeted educational activities. The length of hospital stay is increased in patients with hypokalaemia, shifting the expected length of hospital stay based on the Swiss Diagnosis Related Group classification.
- Gennari FJ. Hypokalemia. N Engl J Med. 1998;339(7):451–8.
- Weiner ID, Wingo CS. Hypokalemia; consequences, causes, and correction. J Am Soc Nephrol. 1997;8(7):1179–88.
- Paltiel O, Salakhov E, Ronen I, Berg D, Israeli A. Management of severe hypokalemia in hospitalized patients: a study of quality of care based on computerized databases. Arch Intern Med. 2001;161(8):1089–95.
- Lippi G, Favaloro EJ, Montagnana M, Guidi GC. Prevalence of hypokalaemia: the experience of a large academic hospital. Intern Med J. 2010;40(4):315–6.
- Greenlee M, Wingo CS, McDonough AA, Youn JH, Kone BC. Narrative review: evolving concepts in potassium homeostasis and hypokalemia. Ann Intern Med. 2009;150(9):619–25.
- Lawson DH, Henry DA, Lowe JM, Gray JM, Morgan HG. Severe hypokalemia in hospitalized patients. Arch Intern Med. 1979;139(9):978–80.
- Paice BJ, Paterson KR, Onyanga-Omara F, Donnelly T, Gray JMB, Lawson DH. Record linkage study of hypokalemia in hospitalized patients. Postgrad Med J 1986;62:187–91.
- Katerinis I, Fumeaux Z. Hypokaliémie: diagnostic et prise en charge. Rev Med Suisse. 2007;3(101);579–82. French.
- Bloomfield RL, Wilson DJ, Buckalew VM Jr. The incidence of diuretic-induced hypokalemia in two distinct clinic settings. J Clin Hypertens. 1986;2(4):331–8.
- Wehling M. Morbus diureticus in the elderly: epidemic overuse of a widely applied group of drugs. J Am Med Dir Assoc. 2013;14(6):437–42.
- Tannen RL. Potassium Disorders. In: JP Kokko. RL Tannen. Differential Diagnosis and Management of Fluid. Electrolyte, and Acid-Base Disorders. WB Saunders, Philadelphia, 197–198, 1986.
- Squires RD, Huth EJ. Experimental potassium depletion in normal human subjects. I. Relation of ionic intakes to the renal conservation of potassium. J Clin Invest. 1959;38;1134–48.
- Palmer BF. Regulation of potassium homeostasis. Clin J Am Soc Nephrol. 2014 May 1; [Epub ahead of print].
- Ernest D1, Chia M, Corallo CE. Profound hypokalaemia due to Nurofen Plus and Red Bull misuse. Crit Care Resusc. 2010;12(2):109–10.
- Lehnhardt A, Kemper MJ. Pathogenesis, diagnosis and management of hyperkalemia. Pediatr Nephrol. 2011;26(3):377–84.
- Crop MJ, Hoorn EJ, Lindemans J, Zietse R. Hypokalaemia and subsequent hyperkalaemia in hospitalized patients. Nephrol Dial Transplant. 2007;22(12):3471–7.
- Wong KC, Schafer PG, Schultz JR. Hypokalemia and anesthetic implications. Anesth Analg. 1993;77(6):1238–60.
- Burton RG, Post T. Clinical Physiology of Acid-Base and Electrolyte Disorders. 5th ed. New York, NY: McGraw-Hill; 2001.
- Tuot D. Too Much, Too Fast. AHRQ WebM&M. http://webmm.ahrq.gov/printviewCase.aspx?caseID=333.
- Gennari FJ. Disorders of potassium homeostasis. Hypokalemia and hyperkalemia. Crit Care Clin. 2002;18:273–88.
- Hemstreet BA, Stolpman N, Badesch DB, May SK, McCollum M. Potassium and phosphorus repletion in hospitalized patients: implications for clinical practice and the potential use of healthcare information technology to improve prescribing and patient safety. Curr Med Res Opin. 2006;22:2449–55.
- “Highalert” medications and patient safety. Int J Qual Health Care. 2001;13:339–40.
- Cohn JN, Kowey PR, Whelton PK, Prisant LM. New guidelines for potassium replacement in clinical practice: a contemporary review by the National Council on Potassium in Clinical Practice. Arch Intern Med. 2000;160(16):2429–36.
- Acker CG, Johnson JP, Palevsky PM, Greenberg A. Hyperkalemia in hospitalized patients: causes, adequacy of treatment, and results of an attempt to improve physician compliance with published therapy guidelines. Arch Intern Med. 1998;158:917–24.
- Harrington L. Potassium protocols: in search of evidence. Clin Nurse Spec. 2005;19:137–41.
- Kim GH, Han JS. Therapeutic approach to hypokalemia. Nephron. 2002;92(suppl 1):28–32.
- Paltiel O, Gordon L, Berg D, Israeli A. Effect of a computerized alert on the management of hypokalemia in hospitalized patients. Arch Intern Med. 2003;163(2):200–4.
- Schiff GD, Klass D, Peterson J, Shah G, Bates DW. Linking laboratory and pharmacy: opportunities for reducing errors and improving care. Arch Intern Med. 2003;163:893–900.
- Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review. Arch Intern Med. 2003;163:1409–16.
- Vitullo F, Carinci F, Lepore V, Tognoni G. Aziende sanitarie e modelli di uso dei DRG. Il Pensiero Scientifico Editore, Roma, 1998.