Clinical rule‐guided pharmacists' intervention in hospitalized patients with hypokalaemia: A time series analysis
What is known and objective Physicians’ response to moderate and severe hypokalaemia in hospitalized patients is frequently suboptimal, leading to increased risk of cardiac arrhythmias and sudden death. While actively alerting physicians on all critical care values using telephone or electronic pop‐...
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| Veröffentlicht in: | Journal of clinical pharmacy and therapeutics 2020-06, Vol.45 (3), p.520-529 |
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| creator | Wasylewicz, Arthur T. M. Korsten, Erik H. M. Egberts, Toine C. G. Grouls, Rene J. E. |
| description | What is known and objective
Physicians’ response to moderate and severe hypokalaemia in hospitalized patients is frequently suboptimal, leading to increased risk of cardiac arrhythmias and sudden death. While actively alerting physicians on all critical care values using telephone or electronic pop‐ups can improve response, it can also lead to alert fatigue and frustration due to non‐specific and overdue alerts. Therefore, a new method was tested. A clinical rule built into a clinical decision support system (CDSS) generated alerts for patients with a serum potassium level (SPL) |
| doi_str_mv | 10.1111/jcpt.13101 |
| format | Article |
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Physicians’ response to moderate and severe hypokalaemia in hospitalized patients is frequently suboptimal, leading to increased risk of cardiac arrhythmias and sudden death. While actively alerting physicians on all critical care values using telephone or electronic pop‐ups can improve response, it can also lead to alert fatigue and frustration due to non‐specific and overdue alerts. Therefore, a new method was tested. A clinical rule built into a clinical decision support system (CDSS) generated alerts for patients with a serum potassium level (SPL) <2.9 mmol/L without a prescription for potassium supplementation. If the alert was deemed clinically relevant, a pharmacist contacted the physician. The aim of this study was to evaluate the impact of the clinical rule‐guided pharmacists’ intervention compared to showing passive alerts in the electronic health records on outcome in patients who developed hypokalaemia (<2.9 mmol/L) during hospitalization.
Methods
A before (2007‐2009) and after (2010‐2017) study with time series design was performed. Pre‐intervention, physicians were shown passive alerts for hypokalaemia in the electronic health records. During the intervention period, in addition to these passive alerts, a pharmacist provided the physician with a specific advice on patients with untreated hypokalaemia, guided by the generated alerts. Unique patients >18 years with SPL <2.9 mmol/L measured at least 24 hours after hospitalization in whom no potassium supplementation was initiated within 4 hours after measurement and normalization of SPL was not achieved within these 4 hours were included. Haemodialysis patients were excluded. The percentage of hypokalaemic patients with a subsequent prescription for potassium supplementation, time to subsequent potassium supplementation prescription, the percentage of patients who achieved normokalaemia (SPL ≥ 3.0 mmol/L), time to achieve normokalaemia and total duration of hospitalization were compared.
Results and discussion
A total of 693 patients were included, of whom 278 participated in the intervention phase. The percentage of patients prescribed supplementation as well as time to prescription improved from 76.0% in 31.1 hours to 92.0% in 11.3 hours (P < .01). Time to achieve SPL ≥3.0 mmol/L improved, P < .009. No changes, however, were observed in the percentage of patients who achieved normokalaemia or time to reach normokalaemia, 87.5% in 65.2 hours pre‐intervention compared to 90.2% (P = .69) in 64.0 hours (P = .71) in the intervention group. A non‐significant decrease of 8.2 days was observed in the duration of hospitalization: 25.4 compared to 17.2 days (P = .29).
What is new and conclusion
Combining CDSS alerting with a pharmacist evaluation is an effective method to improve response rate, time to supplementation and time to initial improvement, defined as SPL ≥3.0 mmol/L. However, it showed no significant effect on the percentage of patients achieving normokalaemia, time to normokalaemia or hospitalization. The discrepancy between rapid supplementation and improvement on the one hand and failure to improve time to normokalaemia on the other warrants further study.
Schematic representation of the chronology of the study design including the alerts generated in both phases of the study. CDSS, computerized decision support system; EHR, electronic health record; SPL, serum potassium level; *alerts were reviewed by a pharmacist. If an alert was found to be potentially clinically relevant, the pharmacist consulted the physician and provided him or her with treatment advice</description><identifier>ISSN: 0269-4727</identifier><identifier>EISSN: 1365-2710</identifier><identifier>DOI: 10.1111/jcpt.13101</identifier><identifier>PMID: 31873951</identifier><language>eng</language><publisher>England: Hindawi Limited</publisher><subject>Aged ; Benchmarking ; Clinical Decision Rules ; clinical decision support systems ; clinical rule ; Decision Support Systems, Clinical - standards ; Electronic Health Records ; Electronic medical records ; Female ; Frustration ; Hemodialysis ; Hospitalization ; Humans ; hypokalaemia ; Hypokalemia ; Hypokalemia - blood ; Hypokalemia - drug therapy ; Male ; Netherlands ; pharmacist ; Pharmacists ; Physicians ; Potassium ; Potassium - blood ; Practice Patterns, Pharmacists' - standards ; Supplements ; Time series ; time series analysis</subject><ispartof>Journal of clinical pharmacy and therapeutics, 2020-06, Vol.45 (3), p.520-529</ispartof><rights>2019 John Wiley & Sons Ltd</rights><rights>2019 John Wiley & Sons Ltd.</rights><rights>Copyright © 2020 John Wiley & Sons Ltd</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c3931-dbf1b2331e5ed63f924c2204c94a35e8418407157fb38e755254b4e0e6d62bac3</citedby><cites>FETCH-LOGICAL-c3931-dbf1b2331e5ed63f924c2204c94a35e8418407157fb38e755254b4e0e6d62bac3</cites><orcidid>0000-0003-1758-7779 ; 0000-0002-1610-6593 ; 0000-0002-6788-9874 ; 0000-0002-7900-3583</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://onlinelibrary.wiley.com/doi/pdf/10.1111%2Fjcpt.13101$$EPDF$$P50$$Gwiley$$H</linktopdf><linktohtml>$$Uhttps://onlinelibrary.wiley.com/doi/full/10.1111%2Fjcpt.13101$$EHTML$$P50$$Gwiley$$H</linktohtml><link.rule.ids>314,776,780,1411,27901,27902,45550,45551</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/31873951$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Wasylewicz, Arthur T. M.</creatorcontrib><creatorcontrib>Korsten, Erik H. M.</creatorcontrib><creatorcontrib>Egberts, Toine C. G.</creatorcontrib><creatorcontrib>Grouls, Rene J. E.</creatorcontrib><title>Clinical rule‐guided pharmacists' intervention in hospitalized patients with hypokalaemia: A time series analysis</title><title>Journal of clinical pharmacy and therapeutics</title><addtitle>J Clin Pharm Ther</addtitle><description>What is known and objective
Physicians’ response to moderate and severe hypokalaemia in hospitalized patients is frequently suboptimal, leading to increased risk of cardiac arrhythmias and sudden death. While actively alerting physicians on all critical care values using telephone or electronic pop‐ups can improve response, it can also lead to alert fatigue and frustration due to non‐specific and overdue alerts. Therefore, a new method was tested. A clinical rule built into a clinical decision support system (CDSS) generated alerts for patients with a serum potassium level (SPL) <2.9 mmol/L without a prescription for potassium supplementation. If the alert was deemed clinically relevant, a pharmacist contacted the physician. The aim of this study was to evaluate the impact of the clinical rule‐guided pharmacists’ intervention compared to showing passive alerts in the electronic health records on outcome in patients who developed hypokalaemia (<2.9 mmol/L) during hospitalization.
Methods
A before (2007‐2009) and after (2010‐2017) study with time series design was performed. Pre‐intervention, physicians were shown passive alerts for hypokalaemia in the electronic health records. During the intervention period, in addition to these passive alerts, a pharmacist provided the physician with a specific advice on patients with untreated hypokalaemia, guided by the generated alerts. Unique patients >18 years with SPL <2.9 mmol/L measured at least 24 hours after hospitalization in whom no potassium supplementation was initiated within 4 hours after measurement and normalization of SPL was not achieved within these 4 hours were included. Haemodialysis patients were excluded. The percentage of hypokalaemic patients with a subsequent prescription for potassium supplementation, time to subsequent potassium supplementation prescription, the percentage of patients who achieved normokalaemia (SPL ≥ 3.0 mmol/L), time to achieve normokalaemia and total duration of hospitalization were compared.
Results and discussion
A total of 693 patients were included, of whom 278 participated in the intervention phase. The percentage of patients prescribed supplementation as well as time to prescription improved from 76.0% in 31.1 hours to 92.0% in 11.3 hours (P < .01). Time to achieve SPL ≥3.0 mmol/L improved, P < .009. No changes, however, were observed in the percentage of patients who achieved normokalaemia or time to reach normokalaemia, 87.5% in 65.2 hours pre‐intervention compared to 90.2% (P = .69) in 64.0 hours (P = .71) in the intervention group. A non‐significant decrease of 8.2 days was observed in the duration of hospitalization: 25.4 compared to 17.2 days (P = .29).
What is new and conclusion
Combining CDSS alerting with a pharmacist evaluation is an effective method to improve response rate, time to supplementation and time to initial improvement, defined as SPL ≥3.0 mmol/L. However, it showed no significant effect on the percentage of patients achieving normokalaemia, time to normokalaemia or hospitalization. The discrepancy between rapid supplementation and improvement on the one hand and failure to improve time to normokalaemia on the other warrants further study.
Schematic representation of the chronology of the study design including the alerts generated in both phases of the study. CDSS, computerized decision support system; EHR, electronic health record; SPL, serum potassium level; *alerts were reviewed by a pharmacist. If an alert was found to be potentially clinically relevant, the pharmacist consulted the physician and provided him or her with treatment advice</description><subject>Aged</subject><subject>Benchmarking</subject><subject>Clinical Decision Rules</subject><subject>clinical decision support systems</subject><subject>clinical rule</subject><subject>Decision Support Systems, Clinical - standards</subject><subject>Electronic Health Records</subject><subject>Electronic medical records</subject><subject>Female</subject><subject>Frustration</subject><subject>Hemodialysis</subject><subject>Hospitalization</subject><subject>Humans</subject><subject>hypokalaemia</subject><subject>Hypokalemia</subject><subject>Hypokalemia - blood</subject><subject>Hypokalemia - drug therapy</subject><subject>Male</subject><subject>Netherlands</subject><subject>pharmacist</subject><subject>Pharmacists</subject><subject>Physicians</subject><subject>Potassium</subject><subject>Potassium - blood</subject><subject>Practice Patterns, Pharmacists' - standards</subject><subject>Supplements</subject><subject>Time series</subject><subject>time series analysis</subject><issn>0269-4727</issn><issn>1365-2710</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2020</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNp90c1OFTEYBuDGSOSAbrwA08QFxGSw_51hR05QISS4wPWk0_nG02Pnx7YDOa64BK6RK7HHgy5Y2E3T9MmbL9-L0FtKTmg-H9d2SieUU0JfoAXlShZMU_ISLQhTVSE00_voIMY1IURpxl-hfU5LzStJFyguvRucNR6H2cPj_cP32bXQ4mllQm-siykeYTckCLcwJDcO-YFXY5xcMt792kqTXP6K-M6lFV5tpvGH8QZ6Z07xGU6uBxwhOIjYDMZvoouv0V5nfIQ3T_ch-vbp_Gb5pbi6_nyxPLsqLK84Ldqmow3jnIKEVvGuYsIyRoSthOESSkFLQTSVumt4CVpKJkUjgIBqFWuM5YfoeJc7hfHnDDHVvYsWvDcDjHOsczbhTEmiMn3_jK7HOeR5t6rSSghS8qw-7JQNY4wBunoKrjdhU1NSb6uot1XUf6rI-N1T5Nz00P6jf3efAd2BO-dh85-o-nL59WYX-hsueJWB</recordid><startdate>202006</startdate><enddate>202006</enddate><creator>Wasylewicz, Arthur T. M.</creator><creator>Korsten, Erik H. M.</creator><creator>Egberts, Toine C. G.</creator><creator>Grouls, Rene J. E.</creator><general>Hindawi Limited</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7T5</scope><scope>7TM</scope><scope>7TO</scope><scope>H94</scope><scope>K9.</scope><scope>M7N</scope><scope>7X8</scope><orcidid>https://orcid.org/0000-0003-1758-7779</orcidid><orcidid>https://orcid.org/0000-0002-1610-6593</orcidid><orcidid>https://orcid.org/0000-0002-6788-9874</orcidid><orcidid>https://orcid.org/0000-0002-7900-3583</orcidid></search><sort><creationdate>202006</creationdate><title>Clinical rule‐guided pharmacists' intervention in hospitalized patients with hypokalaemia: A time series analysis</title><author>Wasylewicz, Arthur T. M. ; Korsten, Erik H. M. ; Egberts, Toine C. G. ; Grouls, Rene J. E.</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c3931-dbf1b2331e5ed63f924c2204c94a35e8418407157fb38e755254b4e0e6d62bac3</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2020</creationdate><topic>Aged</topic><topic>Benchmarking</topic><topic>Clinical Decision Rules</topic><topic>clinical decision support systems</topic><topic>clinical rule</topic><topic>Decision Support Systems, Clinical - standards</topic><topic>Electronic Health Records</topic><topic>Electronic medical records</topic><topic>Female</topic><topic>Frustration</topic><topic>Hemodialysis</topic><topic>Hospitalization</topic><topic>Humans</topic><topic>hypokalaemia</topic><topic>Hypokalemia</topic><topic>Hypokalemia - blood</topic><topic>Hypokalemia - drug therapy</topic><topic>Male</topic><topic>Netherlands</topic><topic>pharmacist</topic><topic>Pharmacists</topic><topic>Physicians</topic><topic>Potassium</topic><topic>Potassium - blood</topic><topic>Practice Patterns, Pharmacists' - standards</topic><topic>Supplements</topic><topic>Time series</topic><topic>time series analysis</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Wasylewicz, Arthur T. M.</creatorcontrib><creatorcontrib>Korsten, Erik H. M.</creatorcontrib><creatorcontrib>Egberts, Toine C. G.</creatorcontrib><creatorcontrib>Grouls, Rene J. E.</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>Immunology Abstracts</collection><collection>Nucleic Acids Abstracts</collection><collection>Oncogenes and Growth Factors Abstracts</collection><collection>AIDS and Cancer Research Abstracts</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Algology Mycology and Protozoology Abstracts (Microbiology C)</collection><collection>MEDLINE - Academic</collection><jtitle>Journal of clinical pharmacy and therapeutics</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Wasylewicz, Arthur T. M.</au><au>Korsten, Erik H. M.</au><au>Egberts, Toine C. G.</au><au>Grouls, Rene J. E.</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Clinical rule‐guided pharmacists' intervention in hospitalized patients with hypokalaemia: A time series analysis</atitle><jtitle>Journal of clinical pharmacy and therapeutics</jtitle><addtitle>J Clin Pharm Ther</addtitle><date>2020-06</date><risdate>2020</risdate><volume>45</volume><issue>3</issue><spage>520</spage><epage>529</epage><pages>520-529</pages><issn>0269-4727</issn><eissn>1365-2710</eissn><abstract>What is known and objective
Physicians’ response to moderate and severe hypokalaemia in hospitalized patients is frequently suboptimal, leading to increased risk of cardiac arrhythmias and sudden death. While actively alerting physicians on all critical care values using telephone or electronic pop‐ups can improve response, it can also lead to alert fatigue and frustration due to non‐specific and overdue alerts. Therefore, a new method was tested. A clinical rule built into a clinical decision support system (CDSS) generated alerts for patients with a serum potassium level (SPL) <2.9 mmol/L without a prescription for potassium supplementation. If the alert was deemed clinically relevant, a pharmacist contacted the physician. The aim of this study was to evaluate the impact of the clinical rule‐guided pharmacists’ intervention compared to showing passive alerts in the electronic health records on outcome in patients who developed hypokalaemia (<2.9 mmol/L) during hospitalization.
Methods
A before (2007‐2009) and after (2010‐2017) study with time series design was performed. Pre‐intervention, physicians were shown passive alerts for hypokalaemia in the electronic health records. During the intervention period, in addition to these passive alerts, a pharmacist provided the physician with a specific advice on patients with untreated hypokalaemia, guided by the generated alerts. Unique patients >18 years with SPL <2.9 mmol/L measured at least 24 hours after hospitalization in whom no potassium supplementation was initiated within 4 hours after measurement and normalization of SPL was not achieved within these 4 hours were included. Haemodialysis patients were excluded. The percentage of hypokalaemic patients with a subsequent prescription for potassium supplementation, time to subsequent potassium supplementation prescription, the percentage of patients who achieved normokalaemia (SPL ≥ 3.0 mmol/L), time to achieve normokalaemia and total duration of hospitalization were compared.
Results and discussion
A total of 693 patients were included, of whom 278 participated in the intervention phase. The percentage of patients prescribed supplementation as well as time to prescription improved from 76.0% in 31.1 hours to 92.0% in 11.3 hours (P < .01). Time to achieve SPL ≥3.0 mmol/L improved, P < .009. No changes, however, were observed in the percentage of patients who achieved normokalaemia or time to reach normokalaemia, 87.5% in 65.2 hours pre‐intervention compared to 90.2% (P = .69) in 64.0 hours (P = .71) in the intervention group. A non‐significant decrease of 8.2 days was observed in the duration of hospitalization: 25.4 compared to 17.2 days (P = .29).
What is new and conclusion
Combining CDSS alerting with a pharmacist evaluation is an effective method to improve response rate, time to supplementation and time to initial improvement, defined as SPL ≥3.0 mmol/L. However, it showed no significant effect on the percentage of patients achieving normokalaemia, time to normokalaemia or hospitalization. The discrepancy between rapid supplementation and improvement on the one hand and failure to improve time to normokalaemia on the other warrants further study.
Schematic representation of the chronology of the study design including the alerts generated in both phases of the study. CDSS, computerized decision support system; EHR, electronic health record; SPL, serum potassium level; *alerts were reviewed by a pharmacist. If an alert was found to be potentially clinically relevant, the pharmacist consulted the physician and provided him or her with treatment advice</abstract><cop>England</cop><pub>Hindawi Limited</pub><pmid>31873951</pmid><doi>10.1111/jcpt.13101</doi><tpages>10</tpages><orcidid>https://orcid.org/0000-0003-1758-7779</orcidid><orcidid>https://orcid.org/0000-0002-1610-6593</orcidid><orcidid>https://orcid.org/0000-0002-6788-9874</orcidid><orcidid>https://orcid.org/0000-0002-7900-3583</orcidid><oa>free_for_read</oa></addata></record> |
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| ispartof | Journal of clinical pharmacy and therapeutics, 2020-06, Vol.45 (3), p.520-529 |
| issn | 0269-4727 1365-2710 |
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| subjects | Aged Benchmarking Clinical Decision Rules clinical decision support systems clinical rule Decision Support Systems, Clinical - standards Electronic Health Records Electronic medical records Female Frustration Hemodialysis Hospitalization Humans hypokalaemia Hypokalemia Hypokalemia - blood Hypokalemia - drug therapy Male Netherlands pharmacist Pharmacists Physicians Potassium Potassium - blood Practice Patterns, Pharmacists' - standards Supplements Time series time series analysis |
| title | Clinical rule‐guided pharmacists' intervention in hospitalized patients with hypokalaemia: A time series analysis |
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