The Hampshire Hospitals Foundation Trust (HHFT) Adult Fluid Prescription Chart 2014 version incorporates the 2013 NICE guideline, CG174 and has been designed to educate and guide all staff involved in the prescription of intravenous fluids for adult inpatients. It contains information about the different constituents of intravenous fluids available for prescription and administration on the adult wards within HHFT. It uses a number of steps intended to be used as an 'aide memoir' when adult intravenous fluid prescription is contemplated and aims to improve patient safety in this area of clinical practice.
- Dr Catherine Jordan, Foundation Year Two Doctor, email@example.com
- Dr Emma Rogers, CT1 in Anaesthesia, firstname.lastname@example.org
- Dr Richard Thomas, Consultant in Anaesthesia and ICU, Richard.email@example.com
Aims and objectives
The design of the HHFT adult intravenous fluid prescription chart provides a step by step "in situ" guide for all staff involved in the prescription and administration of intravenous fluids for adult inpatients. It contains information about the different constituents of intravenous fluids available for prescription and administration on the adult wards within HHFT. It uses a number of steps intended to be used as a bedside "aide memoir" when adult intravenous fluid prescription is contemplated and aims to improve patient safety in this area of clinical practice.
Reasons for implementing your project
Audit cycles at two yearly intervals have been performed and the adult IV fluid prescription charts within the trust have been designed and redesigned in response to audit findings. The designs have aimed to improve the quality of adult IV fluid prescription by providing information, guidance and "prompts" so that those using the chart have relevant information immediately to hand.
How did you implement the project
The latest version of the HHFT adult intravenous fluid prescription chart was produced in response to the need to incorporate recommendations in the 2013 NICE guidelines and results of the latest audit cycle demonstrating that the quality of IV fluid prescription did not meet the standards set out in the NICE guidance. The latest audit cycle identified that patients in HHFT were receiving too much sodium and too little potassium associated with the use of balanced salt solutions on the general wards. The design of the chart also incorporates learning obtained from audit cycles performed since 2004. The prescription of Intravenous fluid is often delegated to junior doctors who are often inexperienced in the prescription of IV fluids.
Previous audit cycles have also highlighted the need for a multidisciplinary team model of teaching. It has highlighted the difficulties in prescribing sufficient potassium on the general wards due to misconceptions within the nursing staff regarding IV potassium prescription and the need for a cardiac monitor- there is a culture within the nursing staff at HHFT which resulted in patients receiving 3g of potassium in a litre bag having to have a cardiac monitor.
The HHFT adult intravenous fluid prescription chart is supported by an educational programme targeted at "key" staff involved (Foundation Doctors, anaesthetic/critical care staff, medical students and doctors in training and "team leaders" of multi-disciplinary teams).
Education was focussed at the junior doctors at HHFT. The results of the audit were presented at the HHFT Foundation Doctors Presentation Day and further teaching sessions were delivered to junior doctors as part of the foundation programme teaching and at the pre-shadowing week for junior doctors starting at HHFT. Junior doctors were encouraged to undertake the learning modules on the NICE eLearning website.
The prescription of electrolytes however remained poor. Only 21% of patients received "correct" sodium prescription prior to our intervention and this then worsened to 13% after our intervention. All patients prescribed 'incorrect' sodium were shown to have been prescribed too much. Potassium prescription showed no improvement with only 13% of patients receiving 'correct' amounts of potassium before and after the intervention. All patients prescribed 'incorrect' potassium were shown to have been prescribed too little.
Key learning points
However, the HHFT IV prescription chart has not improved prescription quality in all the key areas examined by audit; since the introduction of balanced salt solutions (Hartmanns and then Plasmalyte-148) to general ward areas standards as defined by NICE CG174 have not been met.
In particular, audit evidence indicates consistent over-prescription of sodium and under-prescription of potassium in association with the popularity of balanced salt solutions on the general wards. These findings are being addressed by educating junior doctors so that they can undertake correct IV fluid prescription. The pharmacy department has also been targeted in order to ensure that there is an appropriate range of IV fluids available so that fluid prescription can be tailored to patient's individual needs. The audits undertaken have not been designed to explore whether IV fluid prescription, that has not met the NICE recommendations, has caused patient harm.
Education in safe adult IV fluid prescription is undertaken regularly and Foundation Doctors are particularly targeted; sessions are included in shadowing/induction and as part of their protected teaching programme.
Other staff groups are included in the educational package that supports the HHFT IV fluid prescription chart as it is recognised that quality of IV fluid prescription requires a focused multi-professional team based model of learning with senior management support. The trust encourages all staff involved in adult IV fluid prescription to undertake the NICE e-learning package At present this is voluntary but HHFT is considering incorporating this as part of mandatory induction training.