Is Oral Electrolyte Replacement More Effective than IV Replacement in the Oncology Population?

March 2013, Vol 4, No 3

Background: Electrolyte abnormalities are the most common laboratory findings in patients with malignancies. Clinical manifestations of several electrolyte deficiencies occur with frequency in malignancy (Hawthorne JL, Schneider SM, Workman ML). Patients who are admitted for chemotherapy regimens as well as for complications post chemo receive electrolyte replacements on a daily basis. Experience has shown consistent patient and staff nurse dissatisfaction with the current replacement protocol. From their skilled nursing judgment, oncology nurses have found that patients can receive up to 500 mL of excess fluids from IV electrolyte replacement, causing unnecessary fluid overload. Another issue that has been identified by oncology nurses with IV replacement is the potential for phlebitis and pain due to administration of IV potassium. Both of these occurrences can lead to increased costs and admission stays.

Objective: The objective of this evidence-based practice (EBP) project is to evaluate the efficacy of giving oncology patients oral electrolyte replacement (OER) as opposed to IV replacement. The expected outcome is that serum electrolyte values will normalize after being given OERs based on the protocol. The goal is to also increase patient satisfaction regarding unnecessary fluid overload, decrease discomfort from IV potassium given peripherally, decrease administration time leading to earlier discharge times, and reduce costs.

Methods: With a multidisciplinary team devised of an oncology physician, PharmD, APN, nurse educator, and staff RN, the original IV electrolyte protocol was revised to include oral options. The revised order set was presented to the hospital Pharmacy Review Committee for physician approval. Upon approval, a pilot study was initiated. Education of the nursing staff was key to the success of the pilot. Once the staff RN identified a decrease in the serum electrolyte value, they assessed the patient for the presence of nausea, vomiting, diarrhea, and mucositis. If all were negative, the nurse was able to proceed with the OER protocol. Data were gathered on a total of 73 instances of OER use regarding nurse compliance as well as the lab values following the replacement.

Results: Overall nurse compliance for using the OER protocol was 95.9%. For potassium, 65.4% of the occurrences using the OER met the target range for the serum level after repletion. For magnesium, 58% of the occurrences using the OER met the target range. For phosphorus, 100% of the occurrences using the OER met the target range.

Conclusions: The overall staff nurse compliance was extremely high. The reason for this is that the staff nurses were ready for the change in protocol. They identified the issues originally and the project team came together because of their requests. It was a smooth transition from using the IV protocol to the OER. Through staff nurse feedback, it was found that a potassium phosphate oral replacement does not exist on the hospital’s formulary, so only sodium phosphate replacement was used. This was vital information because it identified an unanticipated finding and a need to change the OER protocol. In addition to this, data showed that PO magnesium did not work as effectively for moderately low serum levels; however, oral repletion for mildly low serum magnesium levels was successful. Therefore, the parameters on the OER protocol were changed to reflect this finding and will be re-piloted. The PharmD had been gathering data regarding the usages of the original electrolyte protocol over the last five months. When substituting the amount of IV electrolyte replacement with the amount of OER, they were able to tabulate an overall savings of approximately $15,000.

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