Intravenous fluid therapy in children and young people in hospital implementation: getting started

This section highlights 3 areas of the IV fluid therapy in children and young people guideline that could have a big impact on practice and improve quality of care. We identified these with the help of stakeholders and guideline committee members (see the information on approaches to additional consultation in section 10.1 of the manual). The section also gives information on resources to help with implementation.

The challenge: assessment and monitoring

See recommendation 1.2.3 (KPI).

To ensure that children and young people receiving IV fluid therapy are prescribed the appropriate fluids, precise measurement of fluid and electrolyte status is essential. Measuring and documenting key components on an IV fluid balance and/or prescription chart enables clinical staff to monitor changes in patients' fluid balance and helps to ensure the appropriate prescribing of fluids. The guideline specifies the minimum information needed on these charts, and provides clarity on when weight or body surface area is the most effective way to calculate routine maintenance needs.

Recording fluid and electrolyte status to ensure appropriate prescribing

Currently there is no standard fluid balance and prescription chart in the NHS that is used to record fluid and electrolyte status. In addition, there is variation in what is recorded and documented on a patient's chart between hospitals and between units within hospitals. This can make it difficult for clinicians to determine an accurate fluid balance for a patient when they are moving between hospitals and within hospital departments, and when there is more than 1 clinician involved in a patient's care.

Including all the recommended measurements on a chart may mean a change in practice. Using a chart that encompasses all of the aspects considered important in monitoring, prescribing and safely administering IV fluid therapy for children and young people may support implementation.

What can clinicians and department managers do to help?

  • Access and share examples of fluid balance and prescription charts that include all the recommended measurements.

  • Enable roll out of a trust‑wide standard chart for children and young people by, for example, adapting the DHSSPS standard chart for use in local trusts and disseminating to ward staff.

The challenge: identifying fluids for fluid resuscitation and routine maintenance

See recommendations 1.3.1 (KPI), 1.3.2 (KPI), 1.4.3 (KPI) and 1.4.7.

Information for prescribers about the most appropriate intravenous fluid to use in specific circumstances can help ensure that the amount of fluid or electrolytes given restore and maintain fluid balance.

Using appropriate intravenous fluids for resuscitation and routine maintenance

The guideline specifies the use of glucose‑free crystalloids that contain sodium in the range 131–154 mmol/litre for fluid resuscitation, and isotonic crystalloids that contain sodium in the range 131–154 mmol/litre, with and without glucose, for routine maintenance, but does not specify which isotonic fluid to use as there was a lack of evidence to recommend one isotonic crystalloid over another. There are a range of IV fluids available to most healthcare professionals, and some staff who prescribe IV fluids may not know the specific composition of the choices available to them. A table highlighting examples of commonly used IV fluid types and their compositions has been included in the guideline.

What can clinicians and department managers do to help?

  • Display the table showing the IV fluid types for children and young people on wards and share it with doctors in training.

The challenge: lack of training and education in IV fluid therapy in children and young people

See recommendation 1.8.1.

Ensuring education and training for all healthcare professionals involved in prescribing and delivering IV fluid therapy for children and young people is important for patient safety.

Raising awareness of training and education resources

Prescribers are not always aware of the most appropriate IV fluid to use in specific circumstances and as such, the amount of fluid or electrolytes provided can be either too high or too low to restore and maintain fluid and electrolyte balance. The assessment, prescription and administration of IV fluids in children and young people are complex responsibilities involving clinical and biochemical assessment and a good understanding of the principles of fluid physiology. Failures in education and training which contribute to poor fluid management include:

  • poor understanding of the basic principles of fluid balance and a lack of knowledge about fluid management

  • poor fluid balance (chart) documentation

  • poor interpretation of laboratory results

  • inadequate involvement of senior clinicians in fluid management and delegation of fluid prescription to junior members of the team.

There is little formal training and education in IV fluid management to support correct prescribing. Accessible training and education for all clinicians responsible for fluid management can help ensure that morbidity and mortality is minimised.

What can organisations and department managers do to help?

  • Make sure clinicians responsible for IV fluid management are given time to undertake training and education, and that they are assessed and reassessed at regular intervals.

  • Make sure the organisation has access to existing online training.

Need more help?

Further resources are available from NICE (including shared learning examples) that may help to support implementation.

  • The NICE baseline assessment tool can be used by organisations to evaluate whether their practice is in line with the recommendations in this guideline. It can also help organisations to plan activity to meet the recommendations.

  • Uptake data about guideline recommendations and quality standard measures are available.