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Painful Infusions of PotassiumA Potassium Protocol
Eve Holderman, BSN, RN, CPANOctober 21, 2017NYSPANA State Conference
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Objective
To identify strategies for intervention when the patient experiences pain during infusion of potassium.
Demonstrate the impact of relatively simple solutions on patient’s pain.
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Case Study
78 year old female c/o abdominal pain and nausea and vomiting x 1 week, presents in the operating room for a small bowel resection. She has a history of CHF, HTN, ↑cholesterol, CAD, A fib, diabetes on multiple medications including diuretics.
Postop she is slow to recover. Lab calls to report a critical value, K is 2.7. Nurse notifies the surgeon and an order is generated for potassium replacement.
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Anticipated outcome
Normal Potential Problems
Recovery benchmarks Fluid & electrolyte balanceManage underlying
conditions Return to regular activity
Poor recovery Exacerbation of primary
conditions Phlebitis Vascular injury Cellulitis Increased LOS Increased $$$ Poor outcome
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Role of Potassium
Hypokalemia:Most common cause- GI loss Diuretics- GU loss
Clinical PictureMuscle weakness/spasticityLethargicCardiac dysrhythmiaNausea and VomitingFluid Imbalance
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Managing the pain from K+ IV infusion
Where do I start?
• Relieve the discomfort• Get through the situation• Handle the next case betterConsult colleaguesFind a best practice reference Apply some critical thinking
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Dealing with the frustration
No guidelines or references No consensus on intervention Poor Patient/Family Satisfaction Risk of flagging for Med error
What to do next????
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Journey begins
Bring issue to Nursing Practice Council
Solicit interprofessional perspective- Pharmacy & Therapeutic Committee
Search the literature
Explore current practices
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Shared Governance
P&TCommittee
Nursing Leadership Committee
Nursing Practice Council
&Nursing Research
Council
Nursing Informatics
InterprofessionalTask Force
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Organizational Resources
• Administrative awareness/leadership• Interprofessional communication/input • Nurse Practice Council
Evidence based practicePolicy and procedures
• Nursing education Magnet resourcesPractice integration
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Magnet Resources
Bedside Scholars program Clinical Scholar Mentoring Group Magnet Program Coordinator Academic Advisor
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EBP Model: ACE Star
The Research Council uses the Academic Center for Evidence-based Practice (ACE) model of transforming knowledge into evidence-based practice.
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PICO question
Problem-Patients on K+ IV infusion unable to take oral K+ and refuse infusions due to complaint of pain
Intervention-Measure the prevalence of patient complaint/discomfort during K+ IV infusion and identify strategies that reduce pain
Comparison-Compare strategies practiced by RNs
Outcome-Establish a standard of care for pain management at the site of K+ IV infusion
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No standard of care or best practice for pain management of potassium infusions
In the medical literatureIn pharmacy literatureIn nursing literature
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Method-Data collection
• First 3 months (1st quarter): Monitoring of Electronic Health Record for Adverse Drug Event
No events reported!
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Survey design-a joint effort
Successful collaboration betweenPharmacy and Nursing:
To identify KCL order
Fill order
Attach paper survey form
Retrieve form from units
Collate responses for analysis
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Survey
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Methods-Data collection
Second 3 month (2nd quarter):
•Large increase in response rate!
Monitoring by use of paper survey attached to K+IV
infusion delivered to nursing unit
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Results
After 3 months of data collection (SURVEY N=90)
Analysis of Data reported infusion site pain was decreased by the following:
• K+ IV infusion rate lowered—52 %• Ice pack application—17 %• Extremity elevation—16 %• Pre-medicate/other—4 %
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Question????
Have you tried any of these interventions?
What about warm remedies as opposed to cold?
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IV Potassium Protocol
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Steps in EBP process
Analyze the data Present evidence to committees Translate the evidence into development
of a protocol Integrate the protocol into practice Evaluate the effectiveness of the protocol
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Labeling IV Potassium Dose
Nursing- Pharmacy collaboration
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Follow-up Survey
Follow up Peripheral IV KCL Infusion Survey
Survey on Pain at site and Use of Peripheral IV KCL Infusion Algorithm
Please complete each time you give peripheral IV KCL infusion, either bolus or IV maintenance infusion
When patient develops pain* at the infusion site when administering KCL what action did you take:Treatment Check which intervention was
usedCheck which intervention was effective
Application of cool compressApplication of warm compressAdjust rateElevate ExtremityPain Medication administered? Name_______________
Did you use the algorithm found on Pharmacy Homepage
PAIN AT INFUSION SITE (prior to intervention): Pain Scale (1-10) ________
PAIN AT INFUSION SITE (post intervention): Pain Scale (1-10) ________ 8/2017EH/MMA RETURN COMPLETED FORM TO PHARMACY (via pneumatic tube)
Attach Patient Label
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Nursing Interventions for pain related to Infusion of IV Potassium
52%
17% 16%
4%
60%
36%
21%
3%0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
adjusted rate applied ice pack elevated extremity pre medicated
Interventions for pain relief related to IV Potassium Infusion
pre-protocol post-protocol
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Nursing Interventions for Pain Related to Infusion of IV Potassium
adjusted rate applied ice pack elevated extremity pre medicatedpre-protocol 2015 52% 17% 16% 4%post-protocol 2016 60% 36% 21% 3%post protocol 2017 66% 42% 14% 0%
52%
17% 16%
4%
60%
36%
21%
3%
66%
42%
14%
0%0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
pre-protocol 2015 post-protocol 2016 post protocol 2017
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Average Reported Pain Level related to IV Potassium Infusion
7.3 7.2
3.2
1.5
0
1
2
3
4
5
6
7
8
9
10
2016 2017
Pain
Leve
l
Pain level pre-protocol Pain level post-protocol
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Lessons Learned
Bedside nurse participationInterprofessional collaborationResearch that involves surveys and
questionnaires depends on response rateMissing dataCause of not getting forms returned.
Academic support
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Question?????
Does the pain during infusion of potassium mean the venous system could be harmed??
Are we possibly masking phlebitis??
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Future areas for research
• Multi-site validation through a research study
• Explore clinical items not included in this project Warm compress was not tested.Were there clinical signs and symptoms associated
with low K level.How many orders were D/C’d as the only action
taken
Is there a risk of phlebitis with each infusion?
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Summary
Documented resource
Modify order entry
Nurse-Patient relationship
Improve patient outcomes
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References
Chan, R. & Armstrong, D. (2004). Peripheral intravenous infusion of potassium chloride: Effect of solution composition on infusion-site pain. Journal of Hospital Pharmacology, 57(1), 27-31.
Deguzman, Z. C. et al. (2012) Bacteriostatic normal saline compared with buffered 1% lidocaine when injected intradermally as a local anesthetic to reduce pain during intravenous catheter insertion. Journal of PeriAnesthesia Nursing, 27(6).
Grissinger, M. (2008). Adding lidocaine to IV potassium infusions can cause safety problems. Pharmacy & Therapeutics, 33(2), 70-75.
Gorski, L., et al., (2016), Infusion Therapy Standards of Practice. Journal of Infusion Nursing, 39(1S).
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References
Academic Center for Evidence-based Practice (ACE) model of transforming knowledge into evidence-based practice. The University of Texas Health Science Center at San Antonio (2009) http://www.acestar.uthscsa.edu
Liam, E.T., Kloo, S.T., Tweed, W.A. Efficancy of lignocaine in Alleviating potassium chloride pain. Anesthesia and Intensive Care, 20 (2):196-198.
Melnyk, B.M., Fineout-Overholt, E., Gallagher-Ford, L., Stillwell, S.B.. Sustaining Evidence-Based practice through Organizational Policies and an Innovative Model. AJN, Sept. 2011, Vol. 111, No 9, 57-60.
Gorski, L.A., Hagle, M.E., Birman, S. Intermittently Delivered IV Medication and pH: Reevaluating the evidence. Journal of Infusion Nursing, Jan-Feb 2015, Vol. 38, No 1, 27-46.