The potassium challenge

By surveying and educating clinicians, a project in Central Coast Local Health district was able to improve pain management and reduce waste associated with potassium transfusions to treat hypokalaemia.

Hypokalaemia is a condition categorised by abnormally low levels of potassium in the blood. It is often treated with intravenous (IV) potassium infusions in hospitalised patients. Moderate to severe hypokalaemia can lead to cardiac rhythm abnormalities such as atrial fibrillation or ventricular tachycardia, which can be life-threatening.

Intravenous fluid bags and tubing are made from polyvinyl chloride (PVC), while pouch covers are made from high-density polyethylene. Both materials contribute significantly to hospital waste. Although some PVC recycling programs are in place, access to these programs can vary across each ward. The manufacturing of IV fluid bags and their packaging requires energy, leading to greenhouse gas emissions.

Pain during potassium infusions is common, and in some instances may be preventable by promoting oral replacement instead. Following reports of increased pain during potassium infusions, our multidisciplinary team initiated a series of Plan-Do-Study-Act improvement cycles to investigate the clinical management and prescribing patterns of IV potassium infusions. We gathered information from a literature review, procurement audit, a locally developed staff survey and an Electronic Medical Record (eMR) audit. We found that addressing clinical variability and implementing sustainable practices in potassium replacement could enhance patient experiences, support environmental stewardship and reduce health care costs.

Assessing staff experience with potassium infusion-related pain

We designed a project survey informed by the literature review and previous studies addressing peripheral intravenous cannula care and potassium infusion pain. From October to December 2023, an anonymous online survey was distributed to critical care healthcare professionals at Gosford Hospital and Wyong Hospital. We assessed their experience with:

• potassium infusion-related pain in patients
• management barriers
• patient risk factors.

We used the pharmacy procurement platform Pharmalytix to obtain usage data and conducted a retrospective eMR audit of 150 patients admitted between December 2023 to March 2024. We also extracted data from the eMeds reporting system for three clinical specialties with the highest IV potassium usage: cardiology, emergency and cancer services.

An average decrease of 211 IV bags distributed monthly

A total of 183 staff survey responses were analysed, with a survey completion rate of 97%, representing approximately 21.2% of the critical care workforce. Most respondents were nurses, comprising 81.1% of the participants, who managed potassium infusions daily or weekly primarily through peripheral cannulas. Participants stated that the 10mmol potassium in a 100mL solution was frequently associated with patient pain, with 74.2% reporting that pain occurred 'always' or 'very often'. Barriers to effective pain management included the concentration of potassium and the urgency of treatment.

Among 153 patients audited, two-thirds of IV potassium orders occurred outside business hours. Most patients (86%) received IV potassium peripherally. Documentation gaps hindered our ability to determine pain in 17% of medical records. Of those we could review, 25% reported pain, particularly females (57%) and cardiology inpatients who were older (57%) and therefore more likely to experience pain.

Survey and auditing reveal staff often use several pain management strategies including reducing infusion rates, simple analgesia and topical applications. Less common is abandoning infusions or switching to oral potassium only. Survey comments and audit results suggest IV potassium is overused. We made survey and audit results available to staff via a medication safety notice, the pharmacy intranet, a journal publication and distributed via email.

We collaborated with educational initiatives so that we could share results with junior medical officers (JMOs) and the cardiology medical and nursing teams, and updated the JMO intranet with instructions on electrolyte replacement. Since April 2024, there has been an average monthly decrease of 211 IV potassium bags distributed. This equals a 13% reduction, a saving of 112.4kgCO²e emissions from packaging alone, 38kg reduction in waste,  and a monthly cost saving of $2,350,

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