Standardizing IV Electrolyte Administration in Pediatric Oncology: A Quality Improvement Initiative

Background Intravenous (IV) electrolyte infusions, or electrolyte boluses (EB), are high-alert medications commonly administered to pediatric oncology patients in the inpatient setting. In our institution’s two inpatient oncology units, variation in nursing EB administration practice posed a risk to patients and highlighted an opportunity for standardization. This quality improvement (QI) initiative aimed to standardize IV EB administration for intermittent infusions of IV magnesium sulfate, potassium chloride, potassium phosphate, and calcium gluconate. Methods A multidisciplinary team including nurses, advanced practice providers (APPs), a physician, and a pharmacist was formed. The team first sought to understand why registered nurses (RN) deviated from policy and provider order. We implemented interventions using 10 Plan-Do-Study-Act (PDSA) cycles beginning in January 2022, with the last PDSA cycles implemented in January 2024. Interventions included creating an RN job aid for each of the four EBs, adding these job aids into the electronic “Administration of IV Electrolytes” policy, and modifying the formulary monograph. For APPs, we developed an ordering guide for each EB. We used statistical process control charts to analyze our outcome measure: proportion of EBs administered at the ordered rate. The team used a run chart to track our process measure: the number of times per month a healthcare worker opened the electronic policy document. Results The proportion of EBs administered at the ordered rate increased from 15% to 85% over the observed 36-month period. APPs reported satisfaction with EB ordering guides. The median number of times a healthcare worker accessed the IV electrolyte policy increased from 7 to 110 times per month after all four job aids were added. Conclusions Creating accessible administration job aids for RNs coupled with useful APP ordering guides significantly impacted standardization of administration for high-risk electrolyte infusions in an inpatient pediatric oncology setting. Plain Language Summary Our bodies rely on electrolytes like soluble salts, acids, and bases to ionically conduct electricity for healthy muscle and nerve function. Pediatric oncology patients may experience imbalances in electrolytes resulting from cancer or treatment, which could lead to an oncologic emergency—which is why registered nurses (RNs) carefully manage patients’ electrolyte levels with intravenous (IV) administration of electrolytes. However, the Institute for Safe Medication Practices has designated some IV electrolytes as high-alert medications that carry their own risk of harm if they are used in error. To reduce this risk, one facility embarked on an initiative to improve pediatric care by standardize the ordering and administration of electrolytes. Recognizing that variability in nursing practice regarding high-risk IV infusions could lead to patient harm events, the improvement team studied their existing procedures and challenges around administering large doses (boluses) of electrolytes. They then developed interventions, with the goal of increasing the proportion of administrations where the documented electrolyte bolus (EB) infusion rate matches the ordered EB infusion rate from a baseline of 15% to 60%. Interventions included clarifying and standardizing EB policies, supported by RN job aids and formulary guidance. Due to their efforts, through multiple Plan-Do-Study-Act cycles from January 2022 to March 2024, they surpassed their goal with 85% compliance of EBs administered at the ordered rate.