Hampshire Hospitals NHS Foundation Trust Adult Fluid Prescription Chart 2014

Our aim was to improve the quality of prescription of intravenous fluids for adult inpatients at HHFT. This version of the HHFT adult intravenous fluid prescription chart updates and improves upon previous designs to incorporate recommendations made in the 2013 NICE guidance. This version of the HHFT adult intravenous fluid prescription chart also unifies the paperwork within the trust and replaces the IV fluid prescription charts that were previously 'site specific' (HHFT comprises two inpatient hospitals; Royal Hampshire County Hospital, Winchester and Basingstoke and North Hampshire Hospital, Basingstoke).

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.

Intravenous fluid prescription has been audited for the last 10 years within the Trust. It is recognised that incorrect IV fluid prescription has the potential to cause harm. In addition, it is appreciated that IV fluid prescription is often delegated to junior members of the medical or surgical teams whom may not have received sufficient training in undertaking this task.

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.

Intravenous fluid prescription charts for adult surgical patients were analysed at four discrete data collection intervals. We assessed daily electrolyte monitoring, appropriate volume and electrolyte prescription and documentation of clinical indications and weight. The results were presented to staff members and trust intravenous fluid prescription charts were updated, incorporating the 2013 NICE guidelines. Education was targeted at new Foundation Doctors and prescription practice was resurveyed.

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.

Post implementation of the updated fluid prescription chart at the Trust, a re-audit was undertaken. The results showed that we had successfully implemented the updated prescription charts over the hospital. There was an improvement in the documentation of the indications for IV fluids. Daily electrolyte monitoring improved as we found that 87% of patients receiving intravenous fluids had daily urea and electrolyte monitoring compared to 54% prior to the intervention. 'Correct' IV fluid prescription was defined by reference to the recommendations specified by NICE and the auditors judgement taking into account the clinical state of the patient. For maintenance: 25-30ml/kg fluid, 1mmol/kg Sodium, 1mmol/kg potassium and 50-100g sugar. Patients received more 'correct' volumes of intravenous fluids. Prior to our intervention 41% of patients received 'correct' volumes based on their body weight and clinical history which improved to 50%.

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.

The updated prescription chart aims to guide staff when prescribing and administering intravenous fluids. It uses a 'step by step' approach and guides the prescriber through the process. The chart is popular with all staff groups and has been successfully adopted across the trust.

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.