Quality statement 3: Intravenous fluid management plan

Quality statement

Adults receiving intravenous (IV) fluid therapy in hospital have an IV fluid management plan, determined by and reviewed by an expert, which includes the fluid and electrolyte prescription over the next 24 hours and arrangements for assessing patients and monitoring their plan.

Rationale

Hospital inpatients may need IV fluid and electrolytes for fluid resuscitation, routine maintenance, replacement of existing deficits or abnormal ongoing losses, or complex issues of fluid redistribution. Patients' needs for IV fluid therapy and their responses to it will vary. Careful monitoring and daily assessment, informed by communication between the expert and patients, should therefore be detailed in an IV fluid management plan in the medical record.

Quality measures

Structure

Evidence of local arrangements to ensure that adults receiving IV fluid therapy in hospital have an IV fluid management plan, determined by and reviewed by an expert, which includes the fluid and electrolyte prescription for the next 24 hours and arrangements for assessing patients and monitoring their plan.

Data source: Local data collection.

Process

Proportion of adults receiving IV fluid therapy in hospital who had an IV fluid management plan, determined by and reviewed by an expert, which included daily review of the fluid and electrolyte prescription and arrangements for assessing the patient and monitoring their plan.

Numerator – the number of adults in the denominator who had an IV fluid management plan determined by and reviewed by an expert, which included daily review of the fluid and electrolyte prescription and arrangements for assessing the patient and monitoring their plan.

Denominator – the number of adults receiving IV fluid therapy in hospital.

Data source: Local data collection. Data can also be collected using the NICE clinical guideline 174 clinical audit tool, standards 3 and 4.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as district general hospitals and specialist care centres) ensure that systems are in place for IV fluid management plans to be determined by and reviewed by an expert; plans should include prescriptions over the next 24 hours and arrangements for assessing patients and monitoring their plan.

Healthcare professionals, who are responsible for adults who are receiving IV fluid therapy in hospital,ensure that they determine and review an IV fluid management plan, which includes the fluid and electrolyte prescription for the next 24 hours and arrangements for assessing patients and monitoring their plan.

Commissioners (clinical commissioning groups and NHS England area teams) ensure they commission inpatient services for adults so that IV fluid therapy management plans are determined by and reviewed by an expert and include the fluid and electrolyte prescription for the next 24 hours and arrangements for assessing the patients and monitoring their plan. This can be achieved by auditing hospitals using the IV fluid audit toolkit or by monthly performance monitoring.

What the quality statement means for patients, service users and carers

Adults receiving IV fluid therapy in hospital will know that they have an IV fluid management plan that has been written by and reviewed by an expert. The plan includes the details of the patient's IV fluid prescription (what is needed over the next 24 hours and how it is to be given), as well as details of the IV fluid therapy assessments and checks that should be carried out over the next 24 hours.

Source guidance

Definitions of terms used in this quality statement

Intravenous fluid management plan

The IV fluid management plan should outline the fluid and electrolyte prescription over the next 24‑hour period. It will cover the type, rate and volume of fluid, and how it is to be given. It will be determined by an expert who prescribes IV fluid therapy. Healthcare professionals should follow the IV fluid therapy algorithms in NICE clinical guideline 174.

Assessment

Assessment of adults who are receiving IV fluid therapy will include response to the IV fluid therapy and specific checks for adverse effects of IV fluid therapy. These are described in NICE clinical guideline 174. Assessing and monitoring IV fluid therapy will involve clinical judgement supported by laboratory results.

Monitoring of the plan

The IV fluid management plan should be monitored and reviewed within appropriate timescales. Initially, it should be reviewed daily by an expert. IV fluid management plans for patients on longer-term IV fluid therapy whose condition is stable may be reviewed less frequently. Any decisions to reduce monitoring frequency should be detailed in the IV fluid management plan.

[Adapted from NICE clinical guideline 174, recommendations 1.1.4, 1.1.6, 1.1.8 and 1.2.4]

Expert

NICE clinical guideline 174 defines an expert, in this context, as a healthcare professional who has core competencies to diagnose and manage acute illness. These competencies can be delivered by a variety of models at a local level, such as a critical care outreach team, a hospital-at-night team or a specialist trainee in an acute medical or surgical specialty.