Management of severe hypokalemia in hospitalized patients - A study of quality of care based on computerized databases

Background: While administrative databases are used to assess general indic ators 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 sever e hypokalemia using computerized administrative and laboratory databases. Methods: The study included all patients hospitalized in 1997 who experienc ed serum potassium levels of less than 3.0 mmol/L at Hadassah University Ho spital, Jerusalem, Israel, a tertiary care center. Using the computerized d atabases, we measured the following: (1) whether a subsequent serum potassi um 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 w ere compared with the blinded assessment of the quality of medical manageme nt of hypokalemia, as determined from medical records, using predetermined criteria for adequate management. Results: The computerized databases revealed that severe hypokalemia occurr ed 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 d ischarged from the hospital with a subnormal potassium level. The mean time to a subsequent test was 20 hours, and to normokalemia, 50 hours; both int ervals varied by department. In-hospital mortality was 20.4%, or 10-fold th at of the entire hospitalized population. A review of hospital medical reco rds revealed inadequate clinical management of hypokalemia in 24%, which wa s 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 r atio, 2.1), and in-hospital death likelihood ratio, 2.5), all of which coul d 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.