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Abstract

Introduction: The effectiveness and potential complexity of electrolyte replacement protocols in the surgical population have been described in the literature. Previously, in our SICU and TICU, the electrolyte replacement protocol was not integrated into our computerized physician order entry (CPOE) system. This analysis was undertaken to determine if an electronic protocol integrating clinical decision support (CDS) in our CPOE system would improve electrolyte protocol replacement rates. Methods: This was a single-center, retrospective analysis investigating our nursing-driven electrolyte replacement protocol compliance in June 2010, prior to the CDS ordering process update, and in September 2012, 5 months after the update. Patients were included if at least 16 years of age and admitted to the SICU or TICU with protocol orders for greater than 24 hours. Compliance was assessed with respect to potassium (K), magnesium (Mg), and phosphorus (Phos) replacement doses and follow-up laboratory monitoring. The Mann-Whitney U test was used for continuous data and Fischer’s Exact was used for categorical data. Results: 150 patients were included in this study. 60 patients were in the pre-update 2010 group, and 90 patients were in the post-update 2012 group. Baseline characteristics were similar between groups. Overall initial compliance with K, Mg, and Phos replacement occurred in 2% of patients in 2010 group compared to 17% of patients in the 2012 group (p<0.001). K doses missed per 100 K levels drawn were significantly decreased in the 2012 group (23 per 100 vs 15 per 100 K lab draws, p=0.013). K doses higher than prescribed by the protocol were reduced in the 2012 group, with 8 per 100 vs 3 per 100 K lab draws (p=0.001). Improvements were similar for K doses that were lower than directed. Mg doses missed per 100 Mg levels drawn were improved (37 per 100 vs 13 per 100 Mg lab draws, p<0.001), along with fewer Mg doses that here too high in 2012 (2 per 100 vs 0 per 100 Mg lab draws, p=0.03). No difference in phosphorus replacement was observed. Missed follow-up K levels were reduced in the 2012 group (52 per 100 vs 2 per 100 protocol days, p<0.001). Of the patients with missed doses of K, Mg, and Phos, the average electrolyte values were minimally below the replacement threshold. Conclusions: The electrolyte replacement protocol update integrating CDS in our CPOE system did improve overall compliance, reduced missed K and Mg doses, and helped ensure doses given were correct. We also were able to improve K monitoring in hypokalemic surgical and trauma patients.