Introduction

This quality standard covers the assessment and management of adults' intravenous (IV) fluid needs in hospital. IV fluid therapy is the provision of fluid and/or electrolytes directly into the vein. This quality standard does not cover the use of blood or blood products. For more information see the topic overview.

Why this quality standard is needed

Many adult hospital inpatients need IV fluid therapy to prevent or correct problems with their fluid and/or electrolyte status. This may be because their normal needs cannot be met through enteral routes (for example, they have swallowing problems or gastrointestinal dysfunction) or because they have unusual fluid and/or electrolyte deficits or demands caused by illness or injury (for example, high gastrointestinal or renal losses). Deciding on the optimal amount and composition of IV fluids to be administered and the best rate at which to give them can be a difficult task, and decisions must be based on careful assessment of the patient's individual needs.

Management

Errors in prescribing IV fluids and electrolytes are particularly likely in emergency departments, acute admission units, and general medical and surgical wards rather than in operating theatres and critical care units. Surveys have shown that many staff who prescribe IV fluids know neither the likely fluid and electrolyte needs of individual patients, nor the specific composition of the many choices of IV fluids available to them. Standards of recording and monitoring IV fluid and electrolyte therapy may also be poor in these settings. IV fluid management in hospital is often delegated to the most junior medical staff who frequently lack the relevant experience and may have received little or no specific training on the subject.

The National Confidential Enquiry into Perioperative Deaths report in 1999 highlighted that a significant number of hospitalised patients were dying as a result of infusion of too much or too little fluid. The report recommended that fluid prescribing should be given the same status as drug prescribing. Although mismanagement of fluid therapy is rarely reported as being responsible for patient harm, it is likely that as many as 1 in 5 patients on IV fluids and electrolytes suffer complications or morbidity due to their inappropriate administration.

The quality standard is expected to contribute to improvements in the following outcomes:

  • Mortality or serious harm resulting from errors in IV fluid therapy.

  • Patient experience of hospital care.

  • Patient safety incidents reported.

  • Length of hospital stay.

How this quality standard supports delivery of outcome frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measureable quality improvements within a particular area of health or care. They are derived from high-quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 2 outcomes frameworks published by the Department of Health:

Tables 1 and 2 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 NHS Outcomes Framework 2014/15

Domain

Overarching indicators and improvement areas

1 Preventing people from dying prematurely

Overarching indicator

1a Potential Years of Life Lost (PYLL) from causes amenable to healthcare*

i Adults

4 Ensuring that people have a positive experience of care

Overarching indicator

4b Patient experience of hospital care

Improvement area

Improving hospitals' responsiveness to personal needs

4.2 Responsiveness to in-patients' personal needs

5 Treating and caring for people in a safe environment and protecting them from avoidable harm

Overarching indicators

5a Patient safety incidents reported

5b Safety incidents involving severe harm or death

5c Hospital deaths attributable to problems in care

Improvement area

Reducing the incidence of avoidable harm

5.4 Incidence of medication errors causing serious harm

Alignment across the health and social care system

* Indicator shared with Public Health Outcomes Framework (PHOF)

Table 2 Public health outcomes framework for England, 2013–2016

Domain

Objectives and indicators

4 Healthcare public health and preventing premature mortality

Objective

Reduced numbers of people living with preventable ill health and people dying prematurely, while reducing the gap between communities

Indicator

4.3 Mortality from causes considered preventable*

Alignment across the health and social care system

* Indicator shared with NHS Outcomes Framework (NHSOF)

Coordinated services

The quality standard for IV fluid therapy in adults in hospital specifies that services should be commissioned from and coordinated across all relevant agencies encompassing the whole care pathway. A person-centred, integrated approach to providing services is fundamental to delivering high-quality care to adults in hospital receiving IV fluid therapy.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high-quality services. Other quality standards that should also be considered when choosing, commissioning or providing a high-quality service of IV fluid therapy in adults in hospital are listed in Related quality standards.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All healthcare professionals involved in assessing, caring for and treating adults in hospital receiving IV fluid therapy should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard.

Role of families and carers

Quality standards recognise the important role families and carers have in supporting adults in hospital receiving IV fluid therapy. If appropriate, healthcare professionals should ensure that family members and carers are involved in the decision-making process about investigations, treatment and care.