Quality statement 4: Identifying and reporting consequences of fluid mismanagement

Quality statement

For adults who receive intravenous (IV) fluid therapy in hospital, clear incidents of fluid mismanagement are reported as critical incidents.

Rationale

There are a number of potential adverse consequences of IV fluid therapy, including unnecessarily prolonged dehydration, over hydration or significant electrolyte imbalance, which may be identified by clinical and biochemical monitoring. Not all adverse consequences of IV fluid therapy are due to fluid mismanagement, but clinically significant problems caused by IV fluid mismanagement should be reported as critical incidents. By routinely reporting these events, even when they are well-managed, hospitals will increase learning, improving the likelihood of better patient outcomes.

Quality measures

Structure

Evidence of local arrangements to ensure that clear incidents of fluid mismanagement are reported as critical incidents for adults receiving IV fluid therapy in hospital.

Data source: Local data collection.

Process

Proportion of clear incidents of fluid mismanagement recorded for adults receiving IV fluid therapy in hospital that are reported as critical incidents.

Numerator – the number of clear incidents of fluid mismanagement in the denominator for which a critical incident is reported.

Denominator – the number of clear incidents of fluid mismanagement recorded for adults receiving IV fluid therapy in hospital.

Data source: Local data collection.

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 reporting clear incidents of fluid mismanagement as critical incidents.

Healthcare professionals who care for adults receiving IV fluid therapy in hospital should assess patients' responses to IV fluid therapy and report clear incidents of fluid mismanagement as critical incidents.

Commissioners (clinical commissioning groups and NHS England area teams) ensure that they commission services for adults receiving IV fluid therapy in hospital from providers that report clear incidents of fluid mismanagement as critical incidents. This can be achieved by ensuring that providers share lessons learned from critical incident investigations.

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

Adults receiving IV fluid therapy in hospital are cared for in a hospital that has systems set in place so that IV fluid therapy problems (for example, patients not getting enough IV fluid and becoming severely dehydrated) are reported and dealt with correctly.

Source guidance

Definitions of terms used in this quality statement

Clear incidents of fluid mismanagement

The identification and reporting of incidents of fluid mismanagement should be good practice. It is better to identify and report such incidents than not to identify them, or not to report them if they are identified. Therefore, implementing the quality standard may see an initial increase in incident reporting, reflecting improved identification and reporting rather than worse practice.

Recommendation 1.2.6 (key priority for implementation) in NICE clinical guideline 174 provides the following framework for identifying and reporting adverse consequences in the context of IV fluid management based on Guideline Development Group consensus:

Consequence of fluid mismanagement

Identifying features

Time frame of identification

Hypovolaemia

  • Patient's fluid needs not met by oral, enteral or IV intake and

  • Features of dehydration on clinical examination

  • Low urine output or concentrated urine

  • Biochemical indicators, such as more than 50% increase in urea or creatinine with no other identifiable cause

Before and during IV fluid therapy

Pulmonary oedema

(breathlessness during infusion)

  • No other obvious cause identified (for example, pneumonia, pulmonary embolus or asthma)

  • Features of pulmonary oedema on clinical examination

  • Features of pulmonary oedema on X‑ray

During IV fluid therapy or within 6 hours of stopping IV fluids

Hyponatraemia

  • Serum sodium less than 130 mmol/l

  • No other likely cause of hyponatraemia identified

During IV fluid therapy or within 24 hours of stopping IV fluids

Hypernatraemia

  • Serum sodium 155 mmol/l or more

  • Baseline sodium normal or low

  • IV fluid regimen included 0.9% sodium chloride

  • No other likely cause of hypernatraemia identified

During IV fluid therapy or within 24 hours of stopping IV fluids

Peripheral oedema

  • Pitting oedema in extremities and/or lumbar sacral area

  • No other obvious cause identified (for example, nephrotic syndrome or known cardiac failure)

During IV fluid therapy or within 24 hours of stopping IV fluids

Hyperkalaemia

  • Serum potassium more than 5.5 mmol/l

  • No other obvious cause identified

During IV fluid therapy or within 24 hours of stopping IV fluids

Hypokalaemia

  • Serum potassium less than 3.0 mmol/l likely to be due to infusion of fluids without adequate potassium provision

  • No other obvious cause (for example, potassium-wasting diuretics, refeeding syndrome)

During IV fluid therapy or within 24 hours of stopping IV fluids