Intravenous fluid management is a large part of a foundation doctors workload and the safe prescribing of fluids is part of the foundation programme curriculum. Poor fluid management can lead to serious morbidities. NICE CG174 was produced in response to concerns that significant morbidity is caused by the over and under prescription of IV fluids in hospitals.
The project was set up to ensure knowledge amongst FY1 doctors was sufficient in order to safely prescribe maintenance IV fluids but also to ensure the correct types of fluids were available in order to do so and involved several different departments within the hospital.
Project team members: Dr Michelle McMenamin, Dr Neil Mercer (Consultant Anaesthetists), Dr Benjamin John (FY1), Ms Clare Sales (Pharmacist).
Example
Aims and objectives
The overall aim of the project was to ensure that the most junior medical doctors within the trust had sufficient knowledge in order to prescribe maintenance fluids safely and that the right type of fluids was available in order for them to do so.
Objectives included:
- Assess the base knowledge of FY1 doctors at University Hospital Aintree on Intravenous fluid therapy for adult patients.
- Provide education of the topic through teaching and make the new guidelines accessible using “aide memoire” cards.
- Reassess knowledge of same cohort of doctors after implementation.
Reasons for implementing your project
We investigated the knowledge of the guidelines in our Foundation year one doctors; as they are the personnel most likely to be prescribing IV fluids for our patients.
If we could make a difference to their knowledge of the CG174 guideline, we could inevitably reduce the potential morbidity and mortality as a result of using IV fluids. We also assessed their ability to clinically assess a patient's fluid status, and their knowledge of the daily electrolyte and fluid requirements of an adult patient through a simple questionnaire. The following questions (followed by a percentage giving that answer) were asked having been taken from the guidelines:
Which of these is not a crystalloid?
- 9% saline (5.26%)
- Plasmolyte (2.63%)
- Isoplex (89.47%)
- 5% Dextrose (2.63%)
What is the approximate maintenance requirement for IV fluids?
- 15-20m/kg/day (5.26%)
- 20-25ml/kg/day (13.16%)
- 25-30mll/kg/day (44.74%)
- 30-35ml/kg/day (34.21%)
- 35-40ml/kg/day (2.63%)
What is the approximate daily maintenance requirement of Sodium, Potassium and chloride for a normal adult?
- 2mmol/kg/day (2.63%)
- 5mmol/kg/day (18.42%)
- 0mmol/kg/day (60.53%)
- 5mmol/kg/day (18.42%)
What is the recommended monitoring for patients on daily maintenance fluids?
- No monitoring (2.63%)
- Once weekly renal profile and daily fluid balance (31.58%)
- Daily renal profile (2.63%)
- Daily rental profile, daily fluid balance and twice weekly weights (63.16%)
Have you heard of the “5Rs” when prescribing IV fluids?
- Yes (39.74%)
- No (60.53%)
Once this baseline was established we provided teaching on these subjects. A significant barrier to our trainees prescribing in accordance with the NICE guideline was the lack of appropriate IV fluids in our trust.
Help was enlisted from our pharmacy department; who were able to organise the supply of appropriate fluids and also organised the production of 'aide memoire' cards with the daily electrolyte and fluid requirements of an adult; and also the “5 R’s “as stated in the guideline. Similar cards had previously been successfully used in our trust to increase compliance with antibiotic prescribing guidelines. This was publicised by presentations at our monthly medical and nursing forums. We then asked the same questions to our FY1 doctors to see if the implementation of the teaching, the new cards and the availability of appropriate fluids into the trust had made an impact.
How did you implement the project
We focussed on testing the FY1 doctors on areas of the NICE guideline corresponding to maintenance fluids. All 48 FY1 doctors were invited to answer an initial questionnaire. Five questions were used to maximise return and can be seen within the context section.
The following recommendations from the guidance were tested:
- 1.4.1 If patients need IV fluids for routine maintenance alone, restrict the initial prescription to 25–30 ml/kg/day of water and approximately 1 mmol/kg/day of potassium, sodium and chloride.
- 1.2.4 All patients continuing to receive IV fluids need regular monitoring. This should initially include at least daily reassessments of clinical fluid status, laboratory values (urea, creatinine and electrolytes) and fluid balance charts, along with weight measurement twice weekly .
- 1.6.1 Assessing patients' fluid and electrolyte needs (the 5 Rs: Resuscitation, Routine maintenance, Replacement, Redistribution and Reassessment)
Teaching was then delivered to the cohort. “Aide memoire” lanyard cards and the new fluids were introduced and publicised at the monthly Grand round presentation and nursing forums. Employees at the trust were familiar with only a few types of fluids available for maintenance and so we were challenging standard practises.
The same five questions were asked again to the FY1 doctors and a direct comparison was made between the two results.
One barrier we came up against was who would pay for the lanyard cards. The project was anaesthetist led, but the trainees being educated were from the divisions of medicine and surgery. It was felt to be unlikely that these divisions would agree to pay for a quality improvement that they had not initiated themselves ; in the end Dr Michelle McMenamin procured the funding for the lanyards from the anaesthetic department.
Key findings
The new fluids were rolled out to all areas within the hospital and replaced the traditional fluids. “Aide memoire” cards were successfully generated and distributed at the grand round meeting.
For the questionnaires, results were generated as percentage responding to a particular answer for the question. Direct comparison was made between the two. The initial questionnaire showed that knowledge of different types of fluids was very good amongst the cohort and remained so in the repeat with over 90% answering correctly. We were very pleased to see a vast improvement in the knowledge of daily electrolyte requirements which saw 91.3% answering correctly in the repeat compared to 60.5%.
Similarly we saw an improvement from 44.4% to 56.4% in answering in accordance to the guidelines for daily water requirements. 90% of the cohort answered within 5mmol/kg/day of the recommended amount. Awareness of the “5 R’s” also greatly improved with a 30% increase between the two questionnaires. Variation still remained with regards to monitoring of patients on maintenance IV fluids and we saw a decrease of 7% answering correctly. However the correct answer was still comfortably in the majority at 53%.
Feedback was given that some doctors did not gain access to the lanyard cards and so this was addressed accordingly. Even with this in mind, we feel we have demonstrated that base knowledge has improved amongst the FY1's over maintenance fluid prescriptions.
Key learning points
This exercise has required the organisation and input from several directorates across the trust. A change on this scale needs an MDT approach and liaising with leads in every department.
It is important to reflect on what has worked well in the past and to use that in order to maximise compliance. We knew that lanyard cards are popular amongst medical staff within the trust and have been successful in other quality improvement projects.
If doing questionnaires, keep them short to increase return rate. The initial survey had 10 questions in it and when reviewed, it was felt far too long to keep people motivated in answering.