Potassium Chloride Going, goinggone

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Potassium ChlorideGoing, goinggone!
Alison B Ewing, Clinical Director of
Pharmacy RLBUHT
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Why did we do it ?

• Serious adverse events (including fatalities)
  documented throughout the UK
• September 2001 - fatality within our own Trust
  plus an almost fatal near miss
• Prevailing systems for prescribing, preparing and
  administering potassium solutions show poor
  control.
• All PRIOR to NPSA alert

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To whom did we talk?
K
K

• Working group of senior clinicians (anaesthetist,
  cardiologist, general physician, clinical
  chemist, pharmacist) and the Risk Manager
• Policy developed over 6 months (Nov 2001 May
  2002)
• Approved by DT and Risk Management Group
• Implemented July 2002

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How did we do it ??
COMMUNICATION IS THE MOST VITAL ELEMENT OF THE
PROCESS

• Published policy on intranet
• Told everybody about new policy
• Grand Round presentations
• Training sessions with all ward and junior
  medical staff
  
• Global emails prior to implementation date

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What happened at the change ??

• 3 pharmacy teams visited all clinical areas at
  two hospital sites to remove ampoules supply
  new high strength bags. All done on one day
  Sunday.
• Ensured each area was aware of policy, supplied a
  copy A3 poster.
• Held an ampoule amnesty!

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How did it go ??

• Overall - very successful
• Majority of clinical area staff were fully aware
  of policy implementation
• Full co-operation of all staff obtained
• Change completed at both hospitals within 4 hours
  (Sunday)
• CD supply mechanism for new high strength bags
  works well

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What snags occurred ??

• Some theatre staff claimed not to know anything
  about it !!!
• Insufficient infusion pumps, therefore temporary
  amendment to policy made
• 20mmol DIGAMI regimen variant not well catered
  for temporary co-infusion amendment required
  
• Not everyone reads email!!!!!

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What did we learn ??

• Good communication does work but theres always
  someone who misses it all !!
• Covering all the bases never does !!
• Despite 10 year availability of premixed Alberti
  bags, use of ampoules to make bags still common
  in theatres !!

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Summary of the policy Key Principle

• Intravenous treatment of hypokalaemia must only
  be instigated when the oral/ enteral route is
  unavailable or will not achieve the required
  elevation of serum potassium within a clinically
  acceptable time.

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What people did not know or believe!
Pharmacy Medicines Information Service received
several queries about the policy from hospital
staff

• Have all the ampoules really gone ?
• What bags are available for use ?
• Why have I got these bags - I dont use/ want
  them ?
• Over how long do I infuse the Phosphate bag?

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Summary of the policy
All potassium containing infusions must be
administered via volumetric infusion pump All
patients on IV therapy to have at least once
daily measurement of serum potassium
All IV potassium prescriptions must

• Be expressed as millimoles of potassium
• Include the rate of infusion
• Include the duration of treatment and a programme
  for potassium needs for the following 24-48 hours

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Summary

• This was a very successful venture. It had buy in
  from all levels.
• Pharmacy lead
• Adherence to this policy has significantly
  reduced the risks of incurring the known hazards
  of IV potassium therapy
• The continued compliance of all hospital staff is
  essential for the well-being of patients
• Audit programme established
• So far 100 compliance from audit results