The National Confidential Enquiry into Perioperative Deaths report highlighted that a significant number of hospitalised patients were dying because of infusion of too much or too little fluid. Warrington and Halton Hospitals Foundation Trust, a large district general hospital with 600 beds was committed to addressing this.
The NICE guideline CG174 has provided principles and standards which we feel will underpin a new culture of fluid prescribing and drive a transformational change.
- Use balanced solutions and a patient centred prescription.
- 10 standards of prescribing fluids, taken from the NICE clinical audit tool.
Aims and objectives
- To embed the NICE guideline CG174 into Warrington Hospital culture: right patient right fluid always
- Embed the two CG174 principles of balanced solution and patient centred prescription
- Embed the CG174 10 clinical audit standards of care.
- Meet NCEPOD recommendation 1999: fluid prescribing should be given the same status as drug prescribing.
- Inform and communicate NICE CG174 throughout the Trust
Reasons for implementing your project
The National Confidential Enquiry into Perioperative Deaths report in 1999 highlighted that a significant number of hospitalised patients were dying because of infusion of too much or too little fluid. Warrington and Halton Hospitals Foundation Trust, a large distrist general hospital with 600 beds was committed to addressing this.
In our Trust, and I believe generally, training in IV fluids is dysfunctional. The medical Undergraduate curriculum does not prioritise it. Foundation teaching is inconsistent between different specialities with particularly surgery and anaesthetics teaching different approaches. There has been no review of the evidence base to see if we are providing a quality service or if we could use the evidence base to further cost savings e.g. reduce use of colloids.
The NCEPOD report recommended that fluid prescribing should be given the same status as drug prescribing and we have tried on many occasions to change the culture within the Trust to achieve this. Now NICE have provided principles and standards which we feel will underpin a new culture which will drive a transformational change.
- Use balanced solutions and a patient centred prescription.
- 10 NICE clinical audit standards (based on the NICE guideline) of prescribing fluids during resuscitation, replacement and maintenance.
In 2014, Warrington developed an Acute Care Team (ACT) with a vision to improve all aspects of care related to the deteriorating patient, the primary ambition from the Keogh report. To date the team have had success introducing the acute kidney injury (AKI) pathway and sepsis pathway. During 2015 following the publication of NICE CG174, ACT developed a new IV Fluid Trust policy based on the recommendations from the report. Our aim was to improve patient safety and reduce harm by ensuring that the right patient gets the right fluid, always.
With CG174, the ACT hope to produce a transformational change and embed a new culture based on the 10 clinical audit standards of the NICE guideline and on the 2 principles.
Prior to the change, we audited 10 patient notes from 2015 to review the prescription of peri-op fluids in emergency laparotomies discharged post-op directly to the ward. During this pre-NICE period, we found: preop maintenance was mostly Plasma -Lyte (6 cases) and Normal saline (4 cases), intraop all Plasma-Lyte and postop maintenance was all Plasma-Lyte. In all cases prescription was in ml /hr and not ml/kg/hr.
In developing the guideline, NICE found it necessary to limit the scope and stated that:
"They (the recommendations) do not apply to patients needing inotropes and those on intensive monitoring, and so they have less relevance to intensive care settings and patients during surgical anaesthesia".
Our ICU was looking to standardise our approach to maintenance fluids. On review of the new ICS standards we could find nothing regarding IV fluid therapy. Therefore, our Unit also felt that we should implement NICE recommendations. Data was collected prospectively from patients on the ICU. Patients started on a 24hr maintenance fluid were identified during the daily Consultant ward round.
How did you implement the project
In 2015, ACT produced an IV fluid policy based on the new NICE guideline CG174 (see supporting material). We decided that to achieve the standards from the guideline we should introduce a new IV prescription chart. In the guideline, there are 10 standards covering resus maintenance and replacement.
Our novel idea was to design the new prescription chart around the 10 standards in NICE’s Clinical Audit tool so that when it came to auditing we would be easily able to assess the compliance. The new IV prescription chart was introduced to the Trust in May 2016 (attached as supporting material). The new chart is a daily chart and has information to help in prescribing and assessment.
The IV Policy was one part of a new ACT 10 point IV fluid strategy:
- We designed a NICE IV fluid poster (email attached) which we placed on the door of the IV fluid cupboard on each ward.
- The ACT wore a newly designed t shirt (as seen on poster) again highlighting the change. These were worn for the first few days while putting up the poster and introducing the new IV chart.
- We produced a new survival guide for the Foundation doctors which we called FFFFF: (Five Fluid Facts for Foundation) and was distributed to all Foundation doctors
- New IV fluid critical incident reporting tool and safety alert
- ELearning NICE sent to all foundation doctors to complete.
- IV prescription chart (yellow to match the IV fluid balance sheets)
- App store/nhs-whhemh/policies/iv fluids
- Training programme
- Communication programme
- IV fluid pumps
We insisted that the policy could not be launched without investment in pumps. Interestingly many pumps appeared and no new investment was needed. The only costs of the project were the new IV charts. No other services were affected.
In October 2016, six months after the new chart was in place and with the new foundation doctors embedded in the Trust we did a 1 day point prevalence audit including all patients on IV fluids on the wards.
A point prevalence audit: of IV fluids in the cases of 28 patients was undertaken.
Results found that:
- 26/28 had a pump for fluids
- 26/28 had new yellow IV fluid prescription chart,
- 3/28 had daily fluid prescription charts, although 5/28 were commenced on fluids the same day so may have had daily charts from then on.
- 0/28 had a documented daily assessment on fluid chart,
- 13/28 had fluid rates as ‘mls/hour’
- 6/28 received 0.18% NaCl and 4% glucose alone
- 1/28 received 0.18% NaCL and 4% glucose and plasma-Lyte, with no added K+.
- 4/28 received 0.9% NaCl alone
- 4/28 received 0.9% NaCL and plasma-Lyte, no added K+.
- 12/28 received plasma-Lyte alone.
- 1/28 received plasma-Lyte with isoplex due to profound hypotension.
- 16/28 had a catheter
- 10/28 had no fluid balance or output documented at all
- 7/28 had fluid balance charts but output was not completed
- 11/28 had appropriate output/fluid balance documented
A clear move away from use of 0.9% saline was demonstrated with increased use of 0.18% saline with 4% glucose and plasma-Lyte. More appropriate weight based prescribing was seen, with a significant increase in use of pumps. However, poor documentation of an ABCDE approach or indication for fluids on prescription charts was noted, as was a lack of fluid balance documentation.
On ICU, the most commonly prescribed fluid for these patients was 4% Dextrose with 0.18% Sodium Chloride, 16 out of the 17 patients (94.1%). When comparing the rate of infusion in millilitres per hour, as a ratio of the patient’s weight, an average of 1.072 ml/kg/hr was administered across the 17 patients. Using the NICE guidance of a patient receiving 25ml/kg/day of water, 12 of the 17 patients received less maintenance fluid than the recommended amount (70.59%). 3 patients received more IV fluid over a 24-hour period than NICE recommendations (17.64%), 2 patients received the correct amount of IV fluid over the 24-hour period (11.76%).
Fluid prescribing on our unit is generally well managed and performed to a high standard in accordance with NICE guidelines. The old habit of 125ml/hr standard and stat colloid has gone. In the absence of any ICS or Critical Care Network standards we propose that NICE guidelines CG174 should also be used in ICU.
ICU met our expectations. On the wards, we felt that nursing issues such as pumps and putting IV chart in place were addressed. Unfortunately, medical aspirations e.g. standard of prescription and education fell short and this needs addressing at undergraduate level.
Key learning points
- Find the right enthusiastic team to deliver. Who is the most important factor. We are lucky to have our ACT who we mobilized to introduce the changes quickly.
- Clarify the aim why? We should make clear that we want to achieve the NHS core values of patient centred quality care.
- Have well defined objectives and strategy. Base these on principles, standards and evidence.
- Ensure that equipment is available in this case Iv pumps.
- Design IV chart based on the 10 standards making it easier to measure outcomes.
- Have a collaborative approach with pharmacy. Make sure glucose /saline is available.
- Policy review by drugs and therapeutics committee. They made some great suggestions we had overlooked.
- Stress glucose/saline not dextrose /saline. Small point but we should aim to meet standards of drug prescribing.
- Target foundation doctors.
- IV prescription from doctors not good enough. This is often the case with drug prescription and needs addressing at induction.
- Do not accept that there are not enough pumps. We pushed the Trust on this issue and miraculously the pumps appeared. No new costs were incurred.
- Undergraduate training with IV fluids is poor.
- Remember: Right Patient, Right Fluids, Always