Appropriateness of Potassium Repletion on UCI Wards DSR2 Cost Consciousness Project Jennifer Curtin, PGY-2 1/29/15

Outline 2. Repletion goal - CCU patients vs. everyone else 1. When to replete K+ 2. Repletion goal - CCU patients vs. everyone else 3. How we are doing 4. What we could do better

When to Replete Indications for repletion: - symptomatic or significantly low K+ - ongoing losses (diarrhea, diuresis, etc.) - acute therapy in redistributive conditions (thyrotoxicosis, etc.) Hypokalemia usually causes symptoms when K+ is <3.0 Symptoms can include arrhythmias, EKG changes, anorexia, n/v; muscle weakness & rhabdo can occur with K+ <2.5

When to Replete Quest flags a potassium of <3.5-3.6 as “low” *Of note: Most residents repleted potassium that flagged as low (</=3.5) by Quest's standards (though I didn't look at ongoing losses or presence of symptoms as this wasn't the goal of the study)

Repletion Goal 1. In the CCU ONLY: There was ONE small study showing a mortality benefit in CCU patients when potassium was repleted to a level of 4.0 2. All other patients (including those with cardiac problems or complaints who are NOT in the CCU): There are no strict goals in the guidelines, but a level above the symptomatic threshold with a little room for error (3.5-3.6) would be logical, safe and cost-conscious

How are we doing? Study Question What percentage of patients on UCI wards, who had potassium repleted the morning of 1/24/15, were inappropriately repleted to 3.9 or 4.0?

How are we doing? Methods - Charts were reviewed in alphabetical order under each active team list until at least 1 (up to 2) patients who had potassium repleted on 1/24/15 were obtained from each team, for a total of 10 patients. - The repletion goal for each patient was calculated using the the sum of all replacement potassium ordered that morning and that morning's potassium lab value. - Repletion to a goal of 3.5 or 3.7 was considered appropriate, any higher was considered inappropriate.

How are we doing? Results 33% (3/10) patients who had potassium repleted, were repleted inappropriately (to 4)

Confounders & Useful Further Investigation How are we doing? Confounders & Useful Further Investigation Small sample size (n=10) Consider looking more in depth on when potassium is repleted, and not just to what goal (most repleted when it was 3.5-3.6)

Consider changing the flag cut-off in Quest for low K+ How could we do better? Attending & resident brush-up instruction on when and how much to replete K+ Emphasis on the goal of 4 only applying to CCU patients, not floor patients with cardiac complaints or problems Consider changing the flag cut-off in Quest for low K+

Thank You!