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Management of Severe Hypokalemia in Hospitalized Patients
A Study of Quality of Care Based on Computerized Databases
Ora Paltiel, MD, MSc;
Edouard Salakhov, MD, MPH;
Ilana Ronen, MPH;
David Berg, BSc;
Abraham Israeli, MD, MPH, MSc
Arch Intern Med. 2001;161:1089-1095.
Background While administrative databases are used to assess general indicators
of quality of care, a detailed audit of the process of clinical care usually
requires review of hospital medical records.
Objective To evaluate the feasibility of assessing the management of severe hypokalemia
using computerized administrative and laboratory databases.
Methods The study included all patients hospitalized in 1997 who experienced
serum potassium levels of less than 3.0 mmol/L at Hadassah University Hospital,
Jerusalem, Israel, a tertiary care center. Using the computerized databases,
we measured the following: (1) whether a subsequent serum potassium test was
performed, (2) time to the subsequent test and to normalization of the serum
potassium level, (3) achievement of normokalemia, and (4) in-hospital mortality.
In a random subsample of 100 patients, these measures were compared with the
blinded assessment of the quality of medical management of hypokalemia, as
determined from medical records, using predetermined criteria for adequate
management.
Results The computerized databases revealed that severe hypokalemia occurred
in 866 patients (2.6% of the yearly hospitalizations): 55 patients (6.4%)
had no subsequent serum potassium levels measured, and 260 (30.0%) were discharged
from the hospital with a subnormal potassium level. The mean time to a subsequent
test was 20 hours, and to normokalemia, 50 hours; both intervals varied by
department. In-hospital mortality was 20.4%, or 10-fold that of the entire
hospitalized population. A review of hospital medical records revealed inadequate
clinical management of hypokalemia in 24%, which was associated with nonperformance
of a subsequent test (likelihood ratio, 8.4), failure to normalize the serum
potassium level (likelihood ratio, 4.2), discharge from the hospital with
a subnormal potassium level (likelihood ratio, 2.1), and in-hospital death
(likelihood ratio, 2.5), all of which could be determined by the computerized
databases.
Conclusions The computerized laboratory database is useful in ascertaining the prevalence
of severe hypokalemia and in assessing shortcomings in its management. Databases
can be used to derive valid and efficient measures of the quality of the clinical
management of electrolyte disorders.
From the Departments of Social Medicine (Dr Paltiel and Ms Ronen),
Information Systems (Mr Berg), and Administration (Dr Israeli), Hadassah Medical
Center/Hadassah-Hebrew University and Braun School of Public Health (Dr Israeli),
Jerusalem, Israel.
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