Impact of implementing an order panel for insulin and dextrose dosing for management of hyperkalemia in emergency department patients

PURPOSE: The purpose of this study was to compare the incidence of hypoglycemia before and after implementation of an insulin/dextrose order panel for hyperkalemia in emergency department patients. METHODS: This single-center, retrospective, pre-post cohort study evaluated the impact of an insulin/dextrose order panel for hyperkalemia. The primary endpoint was hypoglycemia incidence before and after panel implementation. Secondary endpoints included the reduction in serum potassium concentration and the incidence of severe hypoglycemia. The panel used real-time creatinine clearance (CrCl) to guide insulin dosing, ordering 5 units of intravenous regular insulin if CrCl was less than 30 mL/min or 10 units if it was 30 mL/min or higher. Dextrose 25 g was added if the blood glucose level was less than 250 mg/dL; otherwise, dextrose was omitted. Hourly point-of-care glucose monitoring occurred for 4 hours following insulin administration beginning 30 minutes after administration. The study period was from November 1, 2021, through April 30, 2023 (preimplementation group) and from June 1 through September 30, 2024 (postimplementation group). RESULTS: A total of 433 patients were included, with 230 in the preimplementation group and 203 in the postimplementation group. Baseline characteristics were similar between the groups, with slightly lower initial potassium levels in the postimplementation group. Hypoglycemia incidence was significantly lower after implementation (23.9% vs 8.9%; P < 0.0001), as was incidence of severe hypoglycemia (10.0% vs 2.5%; P = 0.0015). The median potassium reduction was slightly lower after intervention (1.3 vs 1.1 mEq/L; P = 0.007), but the rate of hyperkalemia resolution was not different between the groups (83.0% vs 88.7%; P = 0.10). CONCLUSION: Implementation of a standardized order panel for insulin and dextrose significantly reduced the incidence of hypoglycemia and severe hypoglycemia in emergency department patients treated for hyperkalemia. These findings support protocol-driven management to improve safety without compromising efficacy.