Optimisation of intravenous fluid prescribing: framework for changing practice through education and audits

The aim of the project was to improve the prescribing of IV fluids for adult inpatients on medical and surgical wards, as in line with the NICE guidance for IV fluids for adults in hospital (CG174). This guidance outlined protocols for IV fluid administration along with recommendations for training and education, focused on more consideration for prescribing fluids specific to patient’s requirements.

Guidance on correct prescription of fluids has hence been adopted by the trust and new IV fluid policy exists (as of May 2014). This local guideline has been updated in line with this.

There have been recent incentives for the correct prescription of IV fluids and new NICE guidance on the prescription of fluids, to ensure that the hydration status of Royal Liverpool and Broadgreen University Hospitals NHS Trust (RLBUHT) patients is assessed, monitored and optimized.

Therefore, the objective of our project has been (and will continue to be) to create a culture in which IV fluids are prescribed with the care, expertise and safety that would be afforded to any other drug.

IV fluids are one of the most commonly prescribed drugs in the hospital setting and yet the practice continues to fall short of NICE guidance (CG174), with significant gaps in staff knowledge exposing patients to heightened morbidity and mortality.

Of all drugs administered in the hospital, IV fluids are one of the most common and yet the importance of well-informed prescribing is often overlooked. Within the 2013 NICE guidelines pertaining to IV fluid prescribing in hospital, it was noted that one in five patients could suffer complications and morbidity because of sub-optimal IV fluid therapy. Many IV fluid prescriptions are hastily written up, often due to time constraints or a perceived lack of importance for the practice. This can lead to inappropriate IV fluid composition, duration, documentation and ultimately, increased morbidity for patients.

Assessment of problem and analysis of cause: 2010–2014

In order to investigate the extent to which the hospital was falling short of the national IV fluid prescribing standards (updated by NICE in 2013), three serial audits were completed between 2010 and 2014. In short, the results demonstrated that wards were consistently failing to reach targets within the realm of IV fluid prescribing, especially in terms of documenting the type, rate and volume of fluid to be administered and then outlining a plan for continued IV fluid therapy and monitoring.

The issue was further highlighted by a hospital-wide staff survey carried out in 2015 involving 136 members of staff. Of this number, 60 were doctors of varying grade, 35 nurses, 11 healthcare assistants, 20 medical students, 3 pharmacists, with the rest made up by various other job descriptions.

The results mirrored those of the audits, showing that just 58% of participants felt adequately prepared to prescribe IV fluids, with the same percentage reporting acceptable knowledge of the various fluid compositions.

Perhaps most significantly, when asked to complete two maintenance fluid prescriptions, only 4.1% were prescribed appropriately. When trying to identify a cause for these findings, it was poor staff knowledge within the IV fluid management, infrequent and inadequate reviews of fluid balance and an endemic trivialisation of IV fluid prescribing on the part of many healthcare professionals that seemed to form the basis for the poor performance.

The audits took place in 2010, 2013, 2014, 2016 and 2017 with an additional hospital-wide staff survey related to IV fluids completed in 2015. The team is led by a consultant chemical pathologist and consists of several junior doctors, pharmacists and nurses and a representative from the clinical audit team.

The work focused on the hospital population indiscriminately so that all adult patients receiving IV fluids on both surgical and medical wards were audited by the team. IV fluid educational week In order to lay the groundwork for the project and establish a baseline level of awareness, the IV fluid team arranged an educational week in the hospital in 2015.

Magnification of the issue was achieved through having ward-based on-the-spot teaching and IV fluid screen-savers available throughout the week. The week concluded with a presentation in Grand Round dedicated to IV fluids and given by the IV fluid team. The session highlighted the risks conferred by poor IV fluid prescribing and described several ways in which staff could take measures to improve their own practice, and that of their colleagues. This included bringing attention to the Trust IV fluid policy and where it could be accessed. The presentation concluded by summarising the educational week survey results (as above under ‘Assessment of problem and analysis of cause: 2010–2014’). Furthermore, at this stage, a bulk email explaining the key issues in relation to IV fluid prescribing in the hospital was sent to all consultants via the Medical Director.

All hospital trusts are expected to offer a comprehensive IV fluid policy based on NICE guidelines but these are usually very word-heavy, non-user friendly documents, thus often remaining foreign to most hospital staff. Consequently, an ‘IV fluid flow chart’ (supporting material appendix) was created from the hospital policy on IV fluids that portrayed the salient information in a digestible and clear manner.

Formal intravenous fluid teaching

The teaching itself involves a 1-hour session that introduces the participant to the inception of IV fluid therapy and the way in which it has evolved over time

Informal intravenous fluid teaching

Provided around the topic of IV fluids was (and still is) provided on the wards by those staff directly involved in the IV fluid audit. The teaching applies this knowledge by explaining the intrinsic link between the indications for IV fluids and the type of IV fluid to be prescribed.

Analysis of 2017 audit results as per NICE standards on IV fluids

- Standard 1: The patient's fluid and electrolyte needs are assessed as part of every ward review

We assessed this standard to have been completed if a clear link was documented in the notes between the patient’s clinical assessment and the need for IV fluids, and treatment with IV fluids was included in the plan. This was achieved in 72% of cases.

- Standard 2: The following information is included in the IV fluid prescription: the type, rate and volume of fluid to be administered

Results indicated that the type and volume of IV fluid was documented in 100% of cases and the rate in 92% of cases.

- Standard 3: Patients have an IV fluid management plan which should include details of the fluid and electrolyte prescription over the next 24 hours, details of assessment (U&E, weight, fluid balance) and details of the monitoring plan

The details of prospective 24 hours fluid and electrolyte prescriptions were only completed in 23% of cases, with many IV fluid plans extending no further than the phrase ‘IV fluids’. In terms of patient assessment, urea and electrolytes were checked in 87% of cases, weight had been documented in 68% of cases and fluid balance fully and partially completed in 64% and 27% of cases, respectively.

- Standard 4: Correct prescription of IV maintenance fluids.

 IV maintenance fluids were prescribed appropriately in 71% of patients (n=103) (Table 1).

- Standard 5: Correct prescription of IV resuscitation fluids

IV resuscitation fluids were prescribed appropriately in 96% of patients (n=29) (Table 1).

Not within NICE standards: correct prescription of IV replacement fluids IV replacement fluids were prescribed appropriately in 75% of cases (n=63) (Table 1).

Table 1 - Comparison of percentage compliance with NICE IV fluid standards (100% compliance) for maintenance, replacement and resuscitation fluids across audit patients

Since the 2015 IV fluid education week and staff survey, the rate at which the gold standard maintenance fluid (as per NICE guidelines) 4% dextrose/0.18% NaCl has increased exponentially (almost 29-fold).

Several positive changes to IV fluid practice in the hospital have arisen.

A marked improvement in the appropriateness of the IV maintenance and replacement fluids prescribed since the March 2016 audit. Moreover, a sharp increase in the use of 4% dextrose/0.18% sodium chloride within the Trust has been observed (Table 2) which suggests a greater awareness of guideline-orientated IV fluid prescribing.

Table 2 - Use of 4% dextrose-0.18% saline bags as maintenance fluid in RLBUHT

It should also be noted that there was almost no discrepancy between the data collected on weekdays compared with weekends (Table 3). It is junior doctors to whom the task of IV fluid prescribing falls and therefore the results would indicate that there exists a better understanding of the relationship between clinical indication and IV fluid choice within this cohort.

Table 3 - Comparison of percentage compliance with NICE IV fluid standards (100% compliance) for maintenance replacement and resuscitation fluids on weekdays versus weekends.

The involvement of several disciplines and varying levels of experience was integral to our project. Our approach was diplomatic not dictatorial, from an early stage getting ideas and feedback from the professional groups that would be affected.

Working in our multi-disciplinary team, we were able to benefit from different areas of expertise.

Key messages:

• There has been an improvement in prescribing appropriate IV fluids since the March 2016 audit and consistency since the September 2016 audit.
• The results on weekends are comparable to those of weekdays.
• There has been a 29-fold increase in use of dextrose/saline within the Trust since IV fluid education began in 2015.