Evaluation of an Updated Hyperkalaemia Treatment Protocol and Electronic Orderset in Hospitalised Patients: Adherence, Safety Outcomes and Effectiveness.
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Date
2025
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Saudi Digital Library
Abstract
Background: Hyperkalaemia is a life-threatening medical emergency, affecting up to 10% of hospital admissions. In 2023, UK guidance and an MHRA safety alert mandated standardised calcium dosing and structured monitoring, but adherence in practice is unknown. This study is the first large-scale UK inpatient evaluation of adherence, monitoring, safety outcomes and effectiveness following implementation of the updated protocol and electronic orderset.
Methods: A retrospective cohort study included adult inpatients (≥18 years) with serum potassium ≥5.5 mmol/L between July-December 2024. Data from the electronic health record were analysed at prescription and episode levels.
Results: A total of 379 prescriptions from 234 hyperkalaemia episodes were analysed. Adherence to the calcium gluconate dose (30 mL) was 93.4% overall, higher with orderset use (94.6% vs. 85.7%) but not statistically significant (p = 0.094). Adherence to the insulin-glucose regimen was 99.1%, with full compliance achieved using the orderset (100% vs. 94.4%, p = 0.004). Post-insulin blood glucose monitoring was poor: only 1.7% of prescriptions achieved the target of ≥9 readings within six hours, while 10.8% had none. Orderset use did not improve compliance (p = 0.621). Hypoglycaemia occurred in 17.2% of treated episodes and hyperglycaemia in 28.6%. Treatment effectiveness showed 65.8% achieved normokalaemia after a single prescription, with outcomes more influenced by baseline severity than prescribing method. Conclusions: The updated protocol achieved high dosing adherence, with the orderset supporting standardisation; however, calcium gluconate underdosing and poor glucose monitoring remain safety risks. Embedding predefined monitoring intervals and reinforcing adherence through education may help address these gaps.
Description
High blood potassium is a dangerous condition that can cause irregular heart rhythms and, if untreated, sudden death. In the UK, new national guidance recommends standardised medicine doses and frequent blood sugar checks, since insulin with glucose (which lowers blood potassium but can affect blood sugar) is a key treatment. Another treatment is calcium gluconate (which protects the heart from high potassium). Some hospitals have built these recommendations into electronic prescribing tools that suggest the recommended medicines and doses.
This study reviewed hospital records from July to December 2024 to assess how well the updated guidance was followed. We checked whether the recommended doses were given, whether blood sugar was monitored as advised, and how effectively treatments lowered potassium. We also compared manual prescribing with use of the electronic tool.
We found that overall adherence to recommended doses was high. When the electronic tool was used, insulin with glucose were always given at the recommended doses, and calcium gluconate dosing was usually correct, although some prescriptions were still too low. Blood sugar checks after insulin were frequently missed, regardless of prescribing method. About one in six patients developed low blood sugar, and one in four developed high blood sugar. Most patients improved after a single treatment, but those with more severe cases often required repeated treatments.
Overall, the updated protocol and electronic tool improved some aspects of care, but important safety gaps remain. These could be reduced by adding automatic blood sugar checks and staff education to ensure consistent practice.
Keywords
Hyperkalaemia, Potassium disorders, Clinical protocol adherence, Electronic orderset, Medication safety, Insulin glucose therapy, Calcium gluconate, Blood glucose monitoring, Dose standardisation, Hypoglycaemia, Hyperglycaemia, Treatment effectiveness, Renal impairment, Chronic kidney disease, Acute kidney injury, Monitoring compliance