We have developed a working group for the introduction of evidence based clinical guidelines for the management of intravenous fluid therapy in adult hospital in patients.
To complement this we have developed two competency documents for assessment – one for prescribers and one for non prescribers. To ensure a good knowledge base we have recommended that as a minimum all prescribers should undertake the NICE e-learning package and this will be supported by ongoing mandatory training
Example
Aims and objectives
Aim: To improve knowledge about the prescription and administration of intravenous fluids throughout the Trust.
Objective: To develop a useable guideline supported by education and competency.
Reasons for implementing your project
Lancashire Teaching Hospitals NHS Foundation Trust serves a population of about 400,000 with tertiary services for Vascular, Neuro and plastic surgery as well as neonatal care. Intravenous fluid management in our Trust has not been satisfactory. This is why this project was set up. The education and training detailed in this project is primarily aimed at our medical students and foundation doctors.
Despite various initiatives such as enhanced recovery- intravenous fluid management has been varied and not necessarily evidence based. Two recent audits one on the surgical side and one on the medical side have confirmed this and the fact that practice was not compliant with the recently published NICE IV fluid guideline. We also had a number of critical incidents relating to fluid management.
The starting point was development of the Intravenous Fluid Management group. From this we developed out own Trust guideline together with competency documents for prescribers and non-prescribers. Medical and nursing leads were set up for each department. We advised that all doctors involved with the prescribing of IV fluid must undertake the NICE e-learning module. Certificates of evidence were collected by the leads and forwarded to our education department who keep records of mandatory training. We then developed an e-learning IV fluid refresher to be undertaken as part of our mandatory training programme.
The implementation of a training programme minimises errors and improved IV fluid management.
How did you implement the project
We commenced a training programme for all involved with intravenous fluid management. This included pharmacists, nursing and medical staff. There were specific tutorial type sessions, lunchtime meetings and also cascade learning which was greatly assisted by our practice educators.
We used the algorithms available from NICE. These were put up as posters on the wards. We also incorporated them into our electronic patient record system so that they are readily available on each computer in the Trust. A foundation doctor within the trust also produced a “ card” for all junior staff as a reference. Our Information Technology department has almost completed developing a software application using these algorithms.
Stickers were produced to be used on daily ward rounds to identify that a fluid management plan was undertaken daily and that the correct assessment had been undertaken to produce this plan. A reminder that a daily management plan was required was incorporated into the section for fluid prescribing on our prescription charts.
We also analysed what intravenous fluids were available within each speciality/ward area and rationalised the types of fluids in these areas.
This was all done in conjunction with a huge drive into work regarding fluid balance and its accurate documentation.
Barriers included a lack of engagement from staff and also the numbers of volumetric pumps for administering fluid.
Key findings
An annual audit has been undertaken with assistance from our clinical effectiveness and audit department. Each directorate was asked to audit 20 sets of notes.
NICE audit standards 1 -4 were used for “routine IV fluids”. The standards used were those advised by NICE from their audit tool. The audit tool can be accessed by clicking here.
- The patient's fluid and electrolyte needs are assessed as part of every ward review.
- The following information is included in the intravenous (IV) fluid prescription:
- the type of fluid to be administered
- the rate of fluid to be administered
- the volume of fluid to be administered
3. Patients have an IV fluid management plan
4. The IV fluid management plan includes the following:
- details of the fluid and electrolyte prescription over the next 24 hours
- details of the assessment
- details of the monitoring plan
The overall compliance is illustrated in the supporting material.
The results of this were at first glance rather disappointing given the amount of improvement work. However, the audit identified a number of reasons why the results were disappointing. For example the quantity of patients and ability to perform timely blood testing especially at weekends, lack of infusion pumps and the requirement for procurement.
We were able to standardise the types of IV fluids on the wards but this has not demonstrated a costs saving.
The results of the audit have enabled us to revisit the opportunity to purchase infusion pumps, and the need for the sticker for the daily ward rounds in various specialities who felt it was not necessary. Our Trust is about to go ahead with electronic prescribing and we hope to embed with this the correct prescribing (type, rate) of fluid.
We hope also to incorporate the audit into our monthly performance targets – essentials of care audit plan.
Key learning points
Establishing a multidisciplinary group, utilising those who are interested.
The multidisciplinary approach is essential to gain understanding of other specialities approach to intravenous fluids, difficulties they may have with compliance and the assistance to inform a wide group of team members.
Support from audit departments and educationalists.
Lessons we learned from the audit included practical difficulties with sampling bloods due to large number of patients. It also became evident that despite our work to improve prescribing and ensure rate was prescribed in “mls/hr, when we audited using NICE audit template the rate was still marked as having been documented even though it may have been prescribed as “8 hourly”. This needs specifying in the re-audit.
Documentation in the notes at the daily ward round is one of our barriers. Our upper gastro-intestinal surgical team use a tick box sticker for each patient at the ward round- stating the management plan discussed, assessment made etc. This has been successful in that speciality and we hope to encourage the use of the same in other specialities.
Targeting newly qualified doctors is easy but changing poor habits in older staff is not. I feel that although we educate our junior staff, it is difficult for them to enforce good practice in their more senior colleagues.