Safety of a Nurse-Driven Standardized Potassium Replacement Protocol in Critically Ill Patients With Renal Insufficiency

Understanding adherence and deviations in potassium replacement protocols: A mixed method study

BACKGROUND

Potassium replacement protocols are commonly used in ICUs to standardise replacement and minimise harm. Yet, there is variability in potassium replacement practices.

AIMS

(i) To examine relationships between potassium levels, potassium administration, and the potassium replacement protocol; and (ii) to explore factors influencing potassium replacement decision-making.

METHODS

An exploratory mixed methods approach using retrospective audit and interviews was undertaken. Clinical data from two ICUs were extracted about potassium results, potassium administration and other related data from the first 72 h of ICU admission, for all patients admitted between January 2015 and December 2022. Critical care nurses were interviewed between January and March 2024, with interviews professionally transcribed and analysed using inductive content analysis.

RESULTS

From the sample of N = 10,613 patients, n = 132,507 potassium results were analysed. Potassium replacement was indicated for 39.7 % (n = 52,592) of potassium results. When replacement was indicated, potassium was administered within 2 h in 59.9 % (n = 31,508) of cases. Interviews with critical care nurses (n = 21) lasted 5-28 min (mean 12 min). Interview participants indicated that potassium replacement decisions were influenced by the patient's history and current condition, and colleague consultation. There was little concern over potential risks associated with potassium replacement. Greater clarity around the purpose and compulsoriness of potassium replacement protocols was desired.

CONCLUSION

These findings offer valuable insights into the intricacies of protocolised potassium replacement adherence and deviations across two ICU settings. Autonomy and interprofessional collaboration emerged as a key factor, with nurses exercising decision-making ability underpinned by patient specific considerations, assessment, and clinical judgement.

IMPLICATIONS FOR CLINICAL PRACTICE

When protocols are used to guide potassium replacement and other electrolytes, clear guidance as to the compulsoriness of the protocol is needed. Alternately, with safety a priority, when and how clinicians may use their clinical judgement and discretion in potassium replacement must also be explicit.

The effect of potassium supplementation and concomitant medications on potassium homeostasis for hospitalized patients

PURPOSE

Hospitalized patients receive potassium (K+) supplementation for hypokalemia, with clinicians often estimating a rise in serum K+ levels of 0.1 mEq/L per 10 mEq delivered. However, there is limited evidence to support this expectation. Patients also concomitantly take medications that may alter K+ levels, and it is not known to what degree these may impact interventions to correct K+ levels via supplementation. The objective of this study was to identify the impact of oral and/or intravenous K+ supplementation on serum K+ levels, including the influence of selected concomitant medications, in adult hospitalized patients.

METHODS

A single-center, retrospective descriptive study of adult hospitalized patients receiving K+ supplementation at a tertiary hospital between 2021 and 2022 was conducted. Patients were included if they received at least one dose of potassium chloride while admitted to the general medicine ward. The primary outcome was the daily median change in serum K+, normalized per 10 mEq of supplementation administered. The secondary outcome was the impact of selected concomitant medication use on supplement-induced changes in serum K+.

RESULTS

A total of 800 patients and 1,291 daily episodes of K+ supplementation were evaluated. The sample was approximately 53% women, was 78% white, and had a median age of 68 years. The overall daily median change in serum K+ level was 0.05 mEq/L per 10 mEq of supplementation delivered. Patients received a median of 40 mEq of supplementation per day, primarily via the oral route (80.6%). Among the concomitant medications assessed, loop diuretics significantly dampened the impact of K+ supplementation.

CONCLUSION

Supplementation of K+ in non-critically ill hospitalized patients is variable and dependent on concomitant medication use.

An integrative review of potassium replacement protocol use in critical care: Development, use and critical care nurse autonomy

BACKGROUND

Potassium replacement protocols are used to standardise practice, reduce risk, and ensure timely potassium replacement, but there is considerable variability in their development and use, particularly as part of critical care nursing practice.

AIM

To synthesise the research evidence on how potassium replacement protocols are used in adult critical care; and how critical care nurses' role and practice is influenced by a potassium replacement protocol. The research question was 'How are protocols used by intensive care clinicians to guide potassium replacement in adult critical care?'

DESIGN

A structured integrative review was undertaken. A combination of keywords, synonyms, and Medical Subject Headings were used across the Ovid Medline and Embase databases. Records were independently assessed against inclusion and exclusion criteria. All papers were assessed for quality. A narrative synthesis was used to analyse and present the findings.

RESULTS

Ten studies were included in this review from 4076 records identified. Narrative synthesis revealed five categories: (i) protocol design demonstrating variation in protocol mechanisms, (ii) protocol rationale eliciting reasonings for protocol implementation, (iii) protocol use describing how protocols were nurse-driven enabling nursing autonomy (iv) protocol adherence highlighting variability in protocol compliance and (v) critical care nurse acceptability and feasibility coupling greater shared responsibility for patient care and improved clinician satisfaction.

CONCLUSION

Safe, high-quality care, supported by evidence continues to be a priority. Protocolised potassium replacement can improve patient outcomes and promote nurses' autonomy, efficiency, and job satisfaction.

IMPLICATIONS FOR CLINICAL PRACTICE

Recognising and promoting critical care nurses' expert assessment skills and clinical decision-making is essential for optimising efficient, safe, and high-quality patient care. Although protocol deviations are accommodated in protocol development, comprehensive documentation to justify protocol deviations is key to justifying practice. Understanding protocol deviations are crucial to inform future protocol development, improvements, and evaluation to further enhance critical care nursing practice.